hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|MO,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Pemiscot Memorial Health System,1/15/2025,2.0.0,Pemiscot Memorial Health System,"946 E Reed St, Hayti, MO 63851",15-67,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|ANTHEM_BCBS_OTHER|COMMERCIAL|negotiated_dollar,standard_charge|ANTHEM_BCBS_OTHER|COMMERCIAL|negotiated_percentage,standard_charge|ANTHEM_BCBS_OTHER|COMMERCIAL|negotiated_algorithm,estimated_amount|ANTHEM_BCBS_OTHER|COMMERCIAL,standard_charge|ANTHEM_BCBS_OTHER|COMMERCIAL|methodology,additional_payer_notes|ANTHEM_BCBS_OTHER|COMMERCIAL,standard_charge|ANTHEM_TRADITIONAL|COMMERCIAL|negotiated_dollar,standard_charge|ANTHEM_TRADITIONAL|COMMERCIAL|negotiated_percentage,standard_charge|ANTHEM_TRADITIONAL|COMMERCIAL|negotiated_algorithm,estimated_amount|ANTHEM_TRADITIONAL|COMMERCIAL,standard_charge|ANTHEM_TRADITIONAL|COMMERCIAL|methodology,additional_payer_notes|ANTHEM_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|CONSOCIATE|MEDICARE|negotiated_dollar,standard_charge|CONSOCIATE|MEDICARE|negotiated_percentage,standard_charge|CONSOCIATE|MEDICARE|negotiated_algorithm,estimated_amount|CONSOCIATE|MEDICARE,standard_charge|CONSOCIATE|MEDICARE|methodology,additional_payer_notes|CONSOCIATE|MEDICARE,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_dollar,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_percentage,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_algorithm,estimated_amount|FIRST_HEALTH|COMMERCIAL,standard_charge|FIRST_HEALTH|COMMERCIAL|methodology,additional_payer_notes|FIRST_HEALTH|COMMERCIAL,standard_charge|HEALTHLINK|MEDICARE|negotiated_dollar,standard_charge|HEALTHLINK|MEDICARE|negotiated_percentage,standard_charge|HEALTHLINK|MEDICARE|negotiated_algorithm,estimated_amount|HEALTHLINK|MEDICARE,standard_charge|HEALTHLINK|MEDICARE|methodology,additional_payer_notes|HEALTHLINK|MEDICARE,standard_charge|HEALTHLINK_HMO|COMMERCIAL|negotiated_dollar,standard_charge|HEALTHLINK_HMO|COMMERCIAL|negotiated_percentage,standard_charge|HEALTHLINK_HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|HEALTHLINK_HMO|COMMERCIAL,standard_charge|HEALTHLINK_HMO|COMMERCIAL|methodology,additional_payer_notes|HEALTHLINK_HMO|COMMERCIAL,standard_charge|HEALTHLINK_PPO|COMMERCIAL|negotiated_dollar,standard_charge|HEALTHLINK_PPO|COMMERCIAL|negotiated_percentage,standard_charge|HEALTHLINK_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|HEALTHLINK_PPO|COMMERCIAL,standard_charge|HEALTHLINK_PPO|COMMERCIAL|methodology,additional_payer_notes|HEALTHLINK_PPO|COMMERCIAL,standard_charge|HEALTHPLAN_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|HEALTHPLAN_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|HEALTHPLAN_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|HEALTHPLAN_MEDICAID|MEDICAID,standard_charge|HEALTHPLAN_MEDICAID|MEDICAID|methodology,additional_payer_notes|HEALTHPLAN_MEDICAID|MEDICAID,standard_charge|HEALTHSCOPE|MEDICARE|negotiated_dollar,standard_charge|HEALTHSCOPE|MEDICARE|negotiated_percentage,standard_charge|HEALTHSCOPE|MEDICARE|negotiated_algorithm,estimated_amount|HEALTHSCOPE|MEDICARE,standard_charge|HEALTHSCOPE|MEDICARE|methodology,additional_payer_notes|HEALTHSCOPE|MEDICARE,standard_charge|HEALTHYBLUE_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|HEALTHYBLUE_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|HEALTHYBLUE_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|HEALTHYBLUE_MEDICAID|MEDICAID,standard_charge|HEALTHYBLUE_MEDICAID|MEDICAID|methodology,additional_payer_notes|HEALTHYBLUE_MEDICAID|MEDICAID,standard_charge|HOME_STATE_HEALTH_PLAN|MEDICARE|negotiated_dollar,standard_charge|HOME_STATE_HEALTH_PLAN|MEDICARE|negotiated_percentage,standard_charge|HOME_STATE_HEALTH_PLAN|MEDICARE|negotiated_algorithm,estimated_amount|HOME_STATE_HEALTH_PLAN|MEDICARE,standard_charge|HOME_STATE_HEALTH_PLAN|MEDICARE|methodology,additional_payer_notes|HOME_STATE_HEALTH_PLAN|MEDICARE,standard_charge|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID,standard_charge|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID|methodology,additional_payer_notes|HOME_STATE_HEALTHPLAN_MEDICAID|MEDICAID,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|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_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|UHC_MEDICARE|MEDICARE,standard_charge|UHC_MEDICARE|MEDICARE|methodology,additional_payer_notes|UHC_MEDICARE|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
R&B GENERAL,790010,CDM,110,RC,,,Inpatient,,,1645,1151.5,,,,,,Other,Not Seperately Reimbusable,1226.4,100,,,Per Diem,Pays based on per day rate,1373.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem ,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,800,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,790,1991.58,
R&B NH ICF PRIVATE,795025,CDM,110,RC,,,Inpatient,,,207,144.9,,,,,,Other,Not Seperately Reimbusable,1226.4,100,,,Per Diem,Pays based on per day rate,1373.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem ,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,800,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,790,1991.58,
R&B NH ICF SEMI,795050,CDM,120,RC,,,Inpatient,,,205,143.5,,,,,,Other,Not Seperately Reimbusable,1226.4,100,,,Per Diem,Pays based on per day rate,1373.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem ,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,800,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,790,1991.58,
R&B NH ICF LOA CONV UP TO 12 D,795051,CDM,182,RC,,,Inpatient,,,205,143.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem ,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1952.53,1991.58,
R&B NH ICF LOA CONV > 12 DAYS,795052,CDM,182,RC,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1991.58,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem ,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable. See MS-DRG rows for rates,1952.53,1991.58,
SOLUSET,211750,CDM,250,RC,Y7507,HCPCS,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,1322.46,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,54.72,
AMINOSYN 3.5%M 1000,212500,CDM,250,RC,Y7507,HCPCS,Outpatient,,,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,230.66,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
AMINOSYN 10% 500ML,212600,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
D5W 50ML IV,212750,CDM,250,RC,Y7507,HCPCS,Outpatient,50,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.38,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DEXTROSE 5% 250ML,212775,CDM,250,RC,,,Outpatient,50,ML,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,53.31,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,255.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
D5W 100ML IV,212800,CDM,250,RC,Y7507,HCPCS,Outpatient,100,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5W 250ML IV,212850,CDM,250,RC,Y7507,HCPCS,Outpatient,50,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,26.66,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5W 250ML EXCEL,212875,CDM,250,RC,J7060,HCPCS,Outpatient,50,ML,37,25.9,,2.12,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,31.55,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
D5W 500ML IV,212900,CDM,250,RC,J7060,HCPCS,Outpatient,500,ML,35,24.5,,2.12,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,138.72,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5 1/4NS 1000CC,213000,CDM,250,RC,J7042,HCPCS,Outpatient,,,35,24.5,,1.75,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5 1/2NS 500CC,213025,CDM,250,RC,Y7507,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,11.97,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5 1/2NS 1000CC,213050,CDM,250,RC,J7042,HCPCS,Outpatient,,,35,24.5,,1.75,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5NS/20KCL  1000ML,213055,CDM,250,RC,S5012,HCPCS,Outpatient,1000,ML,35,24.5,,4.62,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,43.52,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5NS/40KCL  1000ML,213060,CDM,250,RC,S5012,HCPCS,Outpatient,1000,ML,35,24.5,,4.62,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,47.87,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,18.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5W 1/4 10KCL  500ML,213065,CDM,250,RC,,,Outpatient,500,ML,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,176.8,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
D5W/20MEQ  1000ML,213070,CDM,250,RC,,,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,37.54,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
D5W/40KCL  1000ML,213075,CDM,250,RC,,,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,26.11,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
D5LR 1000ML IV,213150,CDM,250,RC,J7042,HCPCS,Outpatient,1000,ML,35,24.5,,1.75,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DEXTROSE 10%/W 1000,213200,CDM,250,RC,,,Outpatient,,,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
DEXTROSE 50% 500ML,213250,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
DEXTROSE 70% 500ML,213300,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,46.24,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,22,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
L.R. 1000ML,213550,CDM,250,RC,,,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
NORMOSOL-M/D5W 500ML,213800,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
NORMAL SALINE 1000ML IV,214250,CDM,250,RC,,,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,13.06,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
SODIUM CHLORIDE 0.45% 100,214290,CDM,250,RC,,,Outpatient,,,132,92.4,,,,,,Other,Not Seperately Reimbusable,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,100.32,76,,35.36,Percent of Total Billed Charges,76% of Total Billed Charges,66,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,85.8,65,,68.64,Percent of Total Billed Charges,65% of Total Billed Charges,99,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,79.2,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.4,100.32,
RHOGAM INJECTION,308962,CDM,250,RC,J2790,HCPCS,Outpatient,,,327,228.9,,89.28,100,,,fee schedule,100% Aetna Market fee schedule,222.36,68,,177.89,Percent of Total Billed Charges,68% of Total Billed Charges,248.52,76,,14.14,Percent of Total Billed Charges,76% of Total Billed Charges,163.5,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.5,248.52,
LIPOSYN III 10% 500ML INJ,213750,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,102,71.4,,,,,,Other,Not Seperately Reimbusable,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,122.82,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
NORMAL SALINE (.9%) 25ML,214110,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,88.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
A & D OINTMENT,600010,CDM,250,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,56.54,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
ACCOLATE 20MG,600012,CDM,250,RC,,,Outpatient,20,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ACCUPRIL 5MG TABLET,600013,CDM,250,RC,,,Outpatient,5,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,173.89,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ACCUPRIL 10MG,600014,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ACCUPRIL 20MG TABLET,600015,CDM,250,RC,,,Outpatient,20,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ACEON 4MG-TAB,600018,CDM,250,RC,,,Outpatient,4,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,102.14,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ABILIFY 2MG TAB,600020,CDM,250,RC,,,Outpatient,2,ME,91,63.7,,,,,,Other,Not Seperately Reimbusable,61.88,68,,49.5,Percent of Total Billed Charges,68% of Total Billed Charges,69.16,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,45.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.15,65,,47.32,Percent of Total Billed Charges,65% of Total Billed Charges,68.25,75,,54.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,54.6,60,,43.68,Percent of Total Billed Charges,60% of Total Billed Charges,18.56,20.4,,14.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.56,20.4,,14.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.2,69.16,
ABILIFY 10MG TAB,600022,CDM,250,RC,,,Outpatient,10,ME,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.65,65,,42.12,Percent of Total Billed Charges,65% of Total Billed Charges,60.75,75,,48.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,48.6,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.2,61.56,
ABILIFY 5MG TAB,600023,CDM,250,RC,Y7140,HCPCS,Outpatient,5,ME,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,300.96,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,49.4,
ABILIFY 15MG TAB,600024,CDM,250,RC,,,Outpatient,15,ME,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,547.2,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.65,65,,42.12,Percent of Total Billed Charges,65% of Total Billed Charges,60.75,75,,48.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,48.6,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.2,61.56,
ACETAMINOPHEN 325MG/12.5ML SYR,600025,CDM,250,RC,,,Outpatient,12.5,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,714.4,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
ACET W/COD ELIXIR,600040,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ACTIGALL 300MG CAPSULE,600308,CDM,250,RC,,,Outpatient,300,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
ACTOS 30MG TABLET,600324,CDM,250,RC,,,Outpatient,30,ME,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36.48,
ACTOS 45MG TABLET,600325,CDM,250,RC,,,Outpatient,45,ME,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,39,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,31.2,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,39.52,
ACULAR 0.5% EYE SOLUTION,600326,CDM,250,RC,Y7506,HCPCS,Outpatient,,,629,440.3,,,,,,Other,Not Seperately Reimbusable,427.72,68,,342.18,Percent of Total Billed Charges,68% of Total Billed Charges,478.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,314.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.5,478.04,
ADALAT CC 30MG TABLET,600329,CDM,250,RC,,,Outpatient,30,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ADALAT CC 60MG TABLET,600330,CDM,250,RC,,,Outpatient,60,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,72.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
ADDERALL 10MG TAB,600333,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,117.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ADDERAL 20MG TABLET,600334,CDM,250,RC,,,Outpatient,20,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,209.15,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ADRENALIN 1:1000 30M,600351,CDM,250,RC,J0171,HCPCS,Outpatient,,,36,25.2,,0.82,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,95.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
ADIPEX-P 37.5MG TABLET,600390,CDM,250,RC,,,Outpatient,375,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,71.74,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,35.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ACYCLOVIR 400MG TAB,600400,CDM,250,RC,,,Outpatient,400,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
ADVAIR 100/50 INH,600500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,480,336,,,,,,Other,Not Seperately Reimbusable,326.4,68,,261.12,Percent of Total Billed Charges,68% of Total Billed Charges,364.8,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,240,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240,364.8,
AEROBID 250MCG-INH,600510,CDM,250,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
AEROCHAMBER,600513,CDM,250,RC,Y7506,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,127.68,76,,46.82,Percent of Total Billed Charges,76% of Total Billed Charges,84,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,127.68,
ADVAIR 250/50 INH,600515,CDM,250,RC,Y7506,HCPCS,Outpatient,,,592,414.4,,,,,,Other,Not Seperately Reimbusable,402.56,68,,322.05,Percent of Total Billed Charges,68% of Total Billed Charges,449.92,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,296,50,,41.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296,449.92,
ADVAIR 500/50 INH,600520,CDM,250,RC,Y7506,HCPCS,Outpatient,,,810,567,,,,,,Other,Not Seperately Reimbusable,550.8,68,,440.64,Percent of Total Billed Charges,68% of Total Billed Charges,615.6,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,405,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,405,615.6,
ADVIL CHILD SUSP 100MG/5ML,600523,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AFRIN 0.05%-INH,600600,CDM,250,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
AGGRENOX 25MG/200MG CAPSULE,600680,CDM,250,RC,,,Outpatient,200,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
AKTEN 3.5% 5ML EYE GEL,600710,CDM,250,RC,,,Outpatient,5,ML,165,115.5,,,,,,Other,Not Seperately Reimbusable,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,125.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,82.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,65,,85.8,Percent of Total Billed Charges,65% of Total Billed Charges,123.75,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,99,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33,125.4,
AK-TROL OPTH OINT 3.5GM-EYE,600714,CDM,250,RC,Y7506,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,49.4,
AK-PRED 1% OPHTHALMIC-EYE,600715,CDM,250,RC,Y7506,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,20.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
AK-SPORE OPTH OINT 3.5GMS-EYE,600727,CDM,250,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
AKWA TEARS OINTMENT 3.5GM,600728,CDM,250,RC,,,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
AK-SPORE HC OINT,600730,CDM,250,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ALBUTEROL SULFATE 0.83% INHALA,600759,CDM,250,RC,J7613,HCPCS,Outpatient,,,9,6.3,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SPIRONOLACTONE 25MG-TAB,601050,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SPIRONOLACTONE 50MG TABLET,601055,CDM,250,RC,Y7506,HCPCS,Outpatient,50,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,26,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ALDOMET 125MG TAB,601098,CDM,250,RC,,,Outpatient,125,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
METHYLDOPA 250MG TAB,601100,CDM,250,RC,,,Outpatient,250,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
METHLDOPA 500MG-TAB,601150,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALDOMET 250MG INJ.,601201,CDM,250,RC,Y7506,HCPCS,Outpatient,250,ME,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
METHYLDOPA/HCTZ 250-15MG-TAB,601250,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHYLDOPA/HCTZ 250-25MG-TAB,601300,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,240.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALLBEE C NA CAP,601447,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,171.46,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ALLBEE W/C CAP,601450,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
ALLEGRA 60MG-CAP,601461,CDM,250,RC,,,Outpatient,60,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ALLEGRA D 60MG/120MG TABLET,601463,CDM,250,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ALTACE 1.25MG CAP,601475,CDM,250,RC,,,Outpatient,125,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALPHAGAN 0.15% GTTS,601476,CDM,250,RC,Y7506,HCPCS,Outpatient,,,235,164.5,,,,,,Other,Not Seperately Reimbusable,159.8,68,,127.84,Percent of Total Billed Charges,68% of Total Billed Charges,178.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,117.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.5,178.6,
ALTACE 2.5MG-CAP,601477,CDM,250,RC,,,Outpatient,25,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ALTACE 5MG TABLET,601479,CDM,250,RC,,,Outpatient,5,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,246.24,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ALUPENT INHALATION 14GM,601480,CDM,250,RC,Y7506,HCPCS,Outpatient,,,196,137.2,,,,,,Other,Not Seperately Reimbusable,133.28,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,148.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,98,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98,148.96,
ALUPENT INHALANT 5%,601485,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
ALUMN. HYDROXIDE 320/5ML,601490,CDM,250,RC,Y7508,HCPCS,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMARYL 2MG-TAB,601503,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMARYL 4MG TABLET,601505,CDM,250,RC,,,Outpatient,4,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
AMBIEN 5MG-TAB,601512,CDM,250,RC,,,Outpatient,5,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,188.48,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
AMBIEN 10MG TABLET,601513,CDM,250,RC,,,Outpatient,10,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
AMERICAINE OINT 20%,601526,CDM,250,RC,Y7506,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
AMICAR 500MG TAB,601550,CDM,250,RC,,,Outpatient,500,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
ACETYLCYSTEINE 10% AEROSOL,601750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,71,49.7,,,,,,Other,Not Seperately Reimbusable,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.5,53.96,
AMINOPHYLLINE 200MG TABLET,601849,CDM,250,RC,,,Outpatient,200,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
AMINOPHYLLINE 500MG SUPP,601900,CDM,250,RC,Y7506,HCPCS,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMINOPHYLLINE 100MG TAB,601950,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMINOPHYLLINE 200MG TABLET,602000,CDM,250,RC,Y7506,HCPCS,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMINOSYN II/DEXTROSE 4.25%-25%,602011,CDM,250,RC,Y7507,HCPCS,Outpatient,,,216,151.2,,,,,,Other,Not Seperately Reimbusable,146.88,68,,117.5,Percent of Total Billed Charges,68% of Total Billed Charges,164.16,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,108,50,,26,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108,164.16,
AMINOSYN 8.5%-I.V. SOLUTION,602012,CDM,250,RC,Y7506,HCPCS,Outpatient,,,295,206.5,,,,,,Other,Not Seperately Reimbusable,200.6,68,,160.48,Percent of Total Billed Charges,68% of Total Billed Charges,224.2,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,147.5,50,,91.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.5,224.2,
AMINOSYN 8.5% W/ELEC 500ML,602015,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ML,311,217.7,,,,,,Other,Not Seperately Reimbusable,211.48,68,,169.18,Percent of Total Billed Charges,68% of Total Billed Charges,236.36,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,155.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.5,236.36,
AMMONIA INHALANT,602100,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,121.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMOXICILLIN CHEWABLE 250MG TAB,602140,CDM,250,RC,,,Outpatient,250,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,151.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
AMOXICILLIN 250MG CAP,602150,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,99.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMOXICILLIN 500MG CAP,602200,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,60.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMOXICILLIN 125MG/5ML-SUSP,602250,CDM,250,RC,,,Outpatient,1255,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMOXIL 250MG/5ML 150ML SUSP,602300,CDM,250,RC,,,Outpatient,250,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
AMOXIL PED DROPS 50MG-PO,602310,CDM,250,RC,,,Outpatient,50,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
AMOXIL 200MG/5ML SUSP,602315,CDM,250,RC,,,Outpatient,200,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
AMOXIL 400MG/5ML SUSPENSION,602320,CDM,250,RC,,,Outpatient,4005,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6303.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMPICILLIN 125MG/5ML-SUSP,602500,CDM,250,RC,,,Outpatient,1255,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,132,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
AMPICILLIN 250MG/5ML 100ML SUS,602504,CDM,250,RC,,,Outpatient,250,ME,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,2550.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
AMPICILLIN 125MG/5ML(100ML)-SU,602507,CDM,250,RC,,,Outpatient,125,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2732,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
AMPICILLIN 250MG/5ML-SUSP,602550,CDM,250,RC,,,Outpatient,250,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2039.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
AMPICILLIAN 250/MG100ML-SUSP,602557,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,119.17,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
AMPICILLIN 250MG CAP,602600,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMPICILLIN 500MG CAP,602650,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,351.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMPICILLIN 125MG INJ,602700,CDM,250,RC,J0290,HCPCS,Outpatient,125,ME,13,9.1,YA,1.11,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
AMPICILLIN 1GM A/V-IV,602825,CDM,250,RC,Y7507,HCPCS,Outpatient,,,60,42,,,,,,Other,Not Seperately Reimbusable,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,45.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,30,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,45.6,
AMPICLN DRP 100MG1ML-PO,603000,CDM,250,RC,,,Outpatient,100,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,178.75,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
NAPROXEN SODIUM 550MG-TAB,603041,CDM,250,RC,,,Outpatient,550,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
CEFAZOLIN 1GM-INJ,603042,CDM,250,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
CEFAZOLIN 2GM INJ IVPB,603043,CDM,250,RC,,,Outpatient,,,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
ANBESOL 20% TUBE,603050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
ANEMAGEN FA CAPSULE,603060,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,60.19,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
ANTI DIARRHEAL 2MG TABLET,603140,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,144.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ANTIPYRINE/BENZOCAINE 54MG/14M,603209,CDM,250,RC,Y7506,HCPCS,Outpatient,5414,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,54.11,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ANTIVENIN POLYVALENT-INJ,603270,CDM,250,RC,Y7506,HCPCS,Outpatient,,,2863,2004.1,,,,,,Other,Not Seperately Reimbusable,1946.84,68,,1557.47,Percent of Total Billed Charges,68% of Total Billed Charges,2175.88,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,1431.5,50,,0.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1431.5,2175.88,
MECLIZINE 25MG TAB,603350,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ANUSOL OINT,603500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ANUSOL HC-1 OINTMENT 1%,603550,CDM,250,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ANZEMET 12.5MG INJ,603575,CDM,250,RC,J1260,HCPCS,Outpatient,125,ME,118,82.6,,7.39,100,,,fee schedule,100% Aetna Market fee schedule,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,63.23,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59,89.68,
HEMMORRHOIDAL OINT,603600,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,76.61,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,30.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HYDROCORTISONE ACETATE 25MG-SU,603650,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,116,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALPRAZOLAM 1MG-TAB,603661,CDM,250,RC,,,Outpatient,1,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
HYDRALAZINE 10MG-TAB,603750,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
APRESOLINE 20MG TAB,603800,CDM,250,RC,,,Outpatient,20,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,85.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
HYDRALAZINE 25MG-TAB,603850,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
APRESOLINE 50MG TAB,603853,CDM,250,RC,,,Outpatient,50,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
AQUAPHOR OINT,603913,CDM,250,RC,Y7506,HCPCS,Outpatient,,,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
ARAMINE 100MG INJ,603950,CDM,250,RC,J0380,HCPCS,Outpatient,100,ME,90,63,,1.09,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
ARICEPT 5MG TABLET,603971,CDM,250,RC,,,Outpatient,5,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
ARIMIDEX 1MG TAB,603990,CDM,250,RC,,,Outpatient,1,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
THYROID 30MG-TAB,604075,CDM,250,RC,,,Outpatient,30,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
TRIHEXYPHENIDYL 2MG TABLET,604150,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ARTHROTEC 75MG TABLET,604160,CDM,250,RC,,,Outpatient,75,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ASPERCREME OINT,604180,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
ASPIRIN EC 325MG TAB,604250,CDM,250,RC,,,Outpatient,325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASACOL 400MG-TAB,604269,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASCORBIC ACID 250MG TAB,604400,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,401.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASPIRIN CHEWABLE,604550,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,366.02,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASPIRIN CHEWABLE 81MG-TAB,604555,CDM,250,RC,,,Outpatient,81,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASPIRIN 325MG TAB,604600,CDM,250,RC,,,Outpatient,325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ASPIRIN 125MG SUPP,604650,CDM,250,RC,Y7506,HCPCS,Outpatient,125,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ASPIRIN 300MG SUPP,604700,CDM,250,RC,Y7506,HCPCS,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,23.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ASPIRIN 600MG SUPP,604750,CDM,250,RC,Y7506,HCPCS,Outpatient,600,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,58.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ASTEPRO SPRAY 205.5MCG-NASAL,604770,CDM,250,RC,Y7506,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,132,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
ASTROGLIDE 2.5OZ,604780,CDM,250,RC,Y7506,HCPCS,Outpatient,,,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
ATACAND 16MG TABLET,604794,CDM,250,RC,,,Outpatient,16,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
HYDROXYZINE 10MG-TAB,604848,CDM,250,RC,,,Outpatient,10,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
HYDROXYZINE 25MG-TAB,604850,CDM,250,RC,,,Outpatient,25,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
HYDROXYZINE HCL 10MG/5ML SYRUP,604880,CDM,250,RC,,,Outpatient,105,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
ATARAX 50MG TAB,604900,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LORAZEPAM 0.5MG-TAB,604972,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ATIVAN 1 MG TAB,604974,CDM,250,RC,,,Outpatient,1,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
ATROPINE 1% EYE SOLUTION,605150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,180,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ATROVENT NASAL 0.06% 15ML,605255,CDM,250,RC,Y7506,HCPCS,Outpatient,15,ML,213,149.1,,,,,,Other,Not Seperately Reimbusable,144.84,68,,115.87,Percent of Total Billed Charges,68% of Total Billed Charges,161.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,106.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.5,161.88,
ATROVENT INHALER,605256,CDM,250,RC,Y7506,HCPCS,Outpatient,,,354,247.8,,,,,,Other,Not Seperately Reimbusable,240.72,68,,192.58,Percent of Total Billed Charges,68% of Total Billed Charges,269.04,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,177,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177,269.04,
ATROVENT .03% AEROSOL,605257,CDM,250,RC,Y7506,HCPCS,Outpatient,,,233,163.1,,,,,,Other,Not Seperately Reimbusable,158.44,68,,126.75,Percent of Total Billed Charges,68% of Total Billed Charges,177.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,116.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.5,177.08,
AUGMENTIN 125/5 75ML SUSP ORAL,605260,CDM,250,RC,,,Outpatient,75,ML,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,89.05,65,,71.24,Percent of Total Billed Charges,65% of Total Billed Charges,102.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,82.2,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.4,104.12,
AUGMENTIN 250MG TAB,605270,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AUGMENTIN 500MG TAB,605272,CDM,250,RC,,,Outpatient,500,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
AUGMENTIN 250MG/5ML-SUSP,605275,CDM,250,RC,,,Outpatient,250,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
AUGMENTIN ES 600MG/5ML SUSP 75,605276,CDM,250,RC,,,Outpatient,,,185,129.5,,,,,,Other,Not Seperately Reimbusable,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,140.6,76,,138.62,Percent of Total Billed Charges,76% of Total Billed Charges,92.5,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,120.25,65,,96.2,Percent of Total Billed Charges,65% of Total Billed Charges,138.75,75,,111,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,111,60,,88.8,Percent of Total Billed Charges,60% of Total Billed Charges,37.74,20.4,,30.19,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.74,20.4,,30.19,Percent of Total Billed Charges,20.4% of Total Billed Charges,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,20,,29.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37,140.6,
AUGMENTIN 250/5 75ML SUSP ORAL,605280,CDM,250,RC,,,Outpatient,75,ML,251,175.7,,,,,,Other,Not Seperately Reimbusable,170.68,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,190.76,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,125.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,163.15,65,,130.52,Percent of Total Billed Charges,65% of Total Billed Charges,188.25,75,,150.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.2,20,,40.16,Percent of Total Billed Charges,20% of Total Billed Charges,150.6,60,,120.48,Percent of Total Billed Charges,60% of Total Billed Charges,51.2,20.4,,40.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,51.2,20.4,,40.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,50.2,20,,40.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.2,20,,40.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.2,190.76,
AUGMENTIN 400MG/5ML SUSPENSION,605282,CDM,250,RC,,,Outpatient,4005,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,184.83,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
AUGMENTIN 400MG/5ML SUSPENSION,605283,CDM,250,RC,,,Outpatient,4005,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,230.43,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
AUGMENTIN 875MG-TAB,605285,CDM,250,RC,,,Outpatient,875,ME,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,78.43,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
AUGMENTIN XR 1000MG TAB,605290,CDM,250,RC,,,Outpatient,1000,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,92.42,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
AURALGAN 15ML OTIC-EAR,605300,CDM,250,RC,Y7506,HCPCS,Outpatient,15,ML,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
AVALIDE 150/12.5MG TABLET,605305,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
AVANDAMET 2MG/500MG,605306,CDM,250,RC,,,Outpatient,2500,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
AVANDIA 4MG TABLET,605307,CDM,250,RC,,,Outpatient,4,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
AVANDAMET 1/500MG TAB,605308,CDM,250,RC,,,Outpatient,1500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,9581.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
AVANDIA 2MG TAB,605309,CDM,250,RC,,,Outpatient,2,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,1733.41,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
AVAPRO 150MG-TAB,605310,CDM,250,RC,,,Outpatient,150,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
AVEENO ANTI ITCH LOTION,605494,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,3877.22,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
AVEENO LOTION,605496,CDM,250,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,4152.64,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,2.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
AVEENO OATMEAL #1,605500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,3099.58,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
AVITENE 1GM-SPONGE,605530,CDM,250,RC,Y7506,HCPCS,Outpatient,,,655,458.5,,,,,,Other,Not Seperately Reimbusable,445.4,68,,356.32,Percent of Total Billed Charges,68% of Total Billed Charges,497.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,327.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.5,497.8,
AXID 150MG TAB,605531,CDM,250,RC,,,Outpatient,150,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
AVODART 0.5MG CAP,605532,CDM,250,RC,,,Outpatient,5,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,533.82,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
AXID 15MG/ML SYRUP 5ML,605535,CDM,250,RC,,,Outpatient,155,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
AZMACORT INHALER,605536,CDM,250,RC,Y7506,HCPCS,Outpatient,,,513,359.1,,,,,,Other,Not Seperately Reimbusable,348.84,68,,279.07,Percent of Total Billed Charges,68% of Total Billed Charges,389.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,256.5,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.5,389.88,
AZOPT 1% -EYE,605633,CDM,250,RC,Y7506,HCPCS,Outpatient,,,189,132.3,,,,,,Other,Not Seperately Reimbusable,128.52,68,,102.82,Percent of Total Billed Charges,68% of Total Billed Charges,143.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,94.5,50,,100.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.5,143.64,
AZULFIDINE 500MG TAB,605700,CDM,250,RC,,,Outpatient,500,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,384.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
B&O 16.2/30 SUPPOSITORY,605720,CDM,250,RC,Y7506,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,98.8,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65,98.8,
BACITRACIN ZINC 1GM OINTMENT,605775,CDM,250,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
"BACITRACIN 50,000U-INJ",605776,CDM,250,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,299.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
"BACITRACIN INJ 50,000 UNITS",605780,CDM,250,RC,Y7506,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,83.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,44.08,
BACLOFEN 10MG-TAB,605790,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SEPTRA IV 160MG/800MG,605797,CDM,250,RC,S0039,HCPCS,Outpatient,,,55,38.5,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
BACTRIM TAB,605800,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
SMX/TMP DS 800MG/160MG-TAB,605850,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,40.74,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SULFAMETHOXAZOLE/TRIMETHO 200M,605900,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BACTRIM 10ML SUSP,605950,CDM,250,RC,,,Outpatient,10,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
BACTRIM 20ML SUSP,605952,CDM,250,RC,,,Outpatient,20,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
BACTROBAN 2% OINT,605953,CDM,250,RC,Y7506,HCPCS,Outpatient,,,239,167.3,,,,,,Other,Not Seperately Reimbusable,162.52,68,,130.02,Percent of Total Billed Charges,68% of Total Billed Charges,181.64,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,119.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.5,181.64,
BACTROBAN 2% CREAM,605954,CDM,250,RC,Y7506,HCPCS,Outpatient,,,192,134.4,,,,,,Other,Not Seperately Reimbusable,130.56,68,,104.45,Percent of Total Billed Charges,68% of Total Billed Charges,145.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,96,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,145.92,
BACTROBAN 0.9GM OINTMENT,605955,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
B COMPLEX VITAMINS PLUS COMB C,605977,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,176.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BECLOVENT INHALER,605979,CDM,250,RC,Y7506,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
BECONASE AQ 0.042% INHALER,605986,CDM,250,RC,Y7506,HCPCS,Outpatient,,,431,301.7,,,,,,Other,Not Seperately Reimbusable,293.08,68,,234.46,Percent of Total Billed Charges,68% of Total Billed Charges,327.56,76,,133.15,Percent of Total Billed Charges,76% of Total Billed Charges,215.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.5,327.56,
BECONASE 16.8G INHALER,605989,CDM,250,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
DIPHENHYDRAMINE 25MG-PO,606150,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,130.11,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BELLERGAL S 40MG/.6MG/.2M TAB,606160,CDM,250,RC,,,Outpatient,4062,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
BENADRYL 1% CREAM,606195,CDM,250,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,43.17,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
HYDRAMINE ELIXIR 12.5MG/5CC-BO,606250,CDM,250,RC,,,Outpatient,1255,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
PROBENECID 500MG TAB,606450,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,226,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BENTYL LIQUID 5ML,606499,CDM,250,RC,,,Outpatient,5,ML,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,41.95,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
BENTYL 20MG/2ML AMP-INJ,606500,CDM,250,RC,J0500,HCPCS,Outpatient,202,ME,49,34.3,,27.46,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
BENTYL 10MG/5ML SYRUP,606501,CDM,250,RC,,,Outpatient,105,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DICYCLOMINE HCI 20MG-TAB,606600,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BENZOIN TOPICAL,606805,CDM,250,RC,Y7506,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
BENZTROPINE 2MG TAB,606810,CDM,250,RC,,,Outpatient,2,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
BENZTROPINE MESYLATE 0.5MG-TAB,606815,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BEROCCA PLUS-PO,606828,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
BEROCCA-PO,606829,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
BETADINE OINT,606898,CDM,250,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,151.39,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
BETADINE 30G OINT,606900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,49.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
BETAGAN0.5% EYE QTTS,606910,CDM,250,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,40.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
BETADINE VAG DOUCHE,606920,CDM,250,RC,Y7506,HCPCS,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
BETAPACE 80MG-TAB,606931,CDM,250,RC,,,Outpatient,80,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,434.8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
BATAMETHASONE 0.05% CREAM 15GM,606932,CDM,250,RC,,,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,10.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
BETOPTIC .5% OPTCL-EYE,606948,CDM,250,RC,,,Outpatient,,,132,92.4,,,,,,Other,Not Seperately Reimbusable,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,100.32,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,66,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.8,65,,68.64,Percent of Total Billed Charges,65% of Total Billed Charges,99,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,79.2,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.4,100.32,
BIAFINE WIDE 3.3-OINT,606962,CDM,250,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,88.77,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
BIAXIN 125MG/5ML-SUSP,606978,CDM,250,RC,,,Outpatient,1255,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
BIAXIN 125MG/5ML EA-SUSP,606979,CDM,250,RC,,,Outpatient,1255,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
BIAXIN 500MG-TAB,606982,CDM,250,RC,,,Outpatient,500,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
BIAXIN XL 500MG TAB,606984,CDM,250,RC,,,Outpatient,500,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
BICILLIN CR 1.2MIL U-INJ,607000,CDM,250,RC,J0561,HCPCS,Outpatient,,,39,27.3,,23.9,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,32.89,
BICILLIN CR 2.4MIL U-INJ,607050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,77,53.9,,,,,,Other,Not Seperately Reimbusable,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,58.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,38.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,58.52,
"BICILLIN CR 300,000 UNITS INJ",607058,CDM,250,RC,J0558,HCPCS,Outpatient,,,17,11.9,YA,19.34,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,26.35,
BICILLIN LA 2.4MIL UNITS INJ,607200,CDM,250,RC,J0580,HCPCS,Outpatient,,,250,175,,,,,,Other,Not Seperately Reimbusable,170,68,,136,Percent of Total Billed Charges,68% of Total Billed Charges,190,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,125,50,,78.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125,190,
SODIUM CITRATE/CIT ACID 30ML,607210,CDM,250,RC,,,Outpatient,30,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,56.54,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SODIUM CITRATE/CIT ACID 1500/1,607221,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BLISTEX LP PROTECTANT,607350,CDM,250,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
BRETHINE 2.5MG TAB,607400,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BRETHINE 5MG TAB,607450,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BRETYLIUM TOSYLATE 500MG/10CC,607575,CDM,250,RC,Y7506,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
BREVITAL SODIUM 500MG-INJ,607581,CDM,250,RC,Y7506,HCPCS,Outpatient,500,ME,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,44.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
BRONCHOLATE 6.25MG/100MG,607624,CDM,250,RC,,,Outpatient,100,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
BSS PLUS-CAP,607741,CDM,250,RC,,,Outpatient,,,356,249.2,,,,,,Other,Not Seperately Reimbusable,242.08,68,,193.66,Percent of Total Billed Charges,68% of Total Billed Charges,270.56,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,178,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,231.4,65,,185.12,Percent of Total Billed Charges,65% of Total Billed Charges,267,75,,213.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.2,20,,56.96,Percent of Total Billed Charges,20% of Total Billed Charges,213.6,60,,170.88,Percent of Total Billed Charges,60% of Total Billed Charges,72.62,20.4,,58.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,72.62,20.4,,58.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,71.2,20,,56.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.2,20,,56.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.2,270.56,
BUMEX 0.5MG/2ML INJ,607804,CDM,250,RC,,,Outpatient,52,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
BUMETANIDE 1MG TAB,607810,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,171.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BUPRENEX 0.3MG INJ,607820,CDM,250,RC,J0592,HCPCS,Outpatient,3,ME,19,13.3,,4.54,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,38.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
BUSPAR 5MG-TAB,607831,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
BUSPAR 10MG-TAB,607834,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
BUSPAR 15MG TABLET,607839,CDM,250,RC,,,Outpatient,15,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,127.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
BUSPIRONE 10MG TABLET,607843,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,159.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
BUTAL 30MG,607845,CDM,250,RC,Y7506,HCPCS,Outpatient,30,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,22.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
BYETTA 250MCG/1.2ML INJ,607850,CDM,250,RC,,,Outpatient,1.2,ML,1060,742,,,,,,Other,Not Seperately Reimbusable,720.8,68,,576.64,Percent of Total Billed Charges,68% of Total Billed Charges,805.6,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,530,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,689,65,,551.2,Percent of Total Billed Charges,65% of Total Billed Charges,795,75,,636,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212,20,,169.6,Percent of Total Billed Charges,20% of Total Billed Charges,636,60,,508.8,Percent of Total Billed Charges,60% of Total Billed Charges,216.24,20.4,,172.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,216.24,20.4,,172.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,212,20,,169.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212,20,,169.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,212,805.6,
BYSTOLIC 5MG TAB,607900,CDM,250,RC,,,Outpatient,5,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1128.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
BEXTRA 10MG TAB,607975,CDM,250,RC,,,Outpatient,10,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
BEXTRA 20MG TAB,607980,CDM,250,RC,,,Outpatient,20,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
BORIC ACID PWD,607990,CDM,250,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
CA CHLORIDE 1G/SYR,608000,CDM,250,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,27.56,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,31.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
CA GLUCEPTAT 2G/5ML-INJ,608050,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
CALADRYL 8%-1% LOTION,608200,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
CALAMINE 6.97% LOTION,608250,CDM,250,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,79.65,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,18.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
VERAPAMIL HCL 80MG TAB,608260,CDM,250,RC,Y7140,HCPCS,Outpatient,80,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,36.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
VERAPAMIL HCL 120MG TABLET,608261,CDM,250,RC,,,Outpatient,120,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CALAN 120MG TAB,608263,CDM,250,RC,,,Outpatient,120,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
VERAPAMIL HCI 80MG-TAB,608264,CDM,250,RC,,,Outpatient,80,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,152.61,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
VERAPAMIL 5MG/2ML INJECTION,608265,CDM,250,RC,,,Outpatient,52,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,584.9,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
CALAN SR 180MG-TAB,608266,CDM,250,RC,,,Outpatient,180,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,478,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
VERAPAMIL HCI 240MG-TAB,608269,CDM,250,RC,,,Outpatient,240,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
CALCIUM 600MG TAB,608281,CDM,250,RC,,,Outpatient,600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,126.46,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,761.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CALCIUM ANACID 750MG TAB,608282,CDM,250,RC,,,Outpatient,750,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,3464.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
CALCIUM CARBONATE 1250MG TABLE,608284,CDM,250,RC,,,Outpatient,250,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
CALCITRATE 950MG TAB,608285,CDM,250,RC,,,Outpatient,950,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CALCIUM D 600MG TABLET,608288,CDM,250,RC,,,Outpatient,600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,246,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CALCIUM CHLORIDE 10%18-G 1GRAM,608290,CDM,250,RC,Y7506,HCPCS,Outpatient,,,209,146.3,,,,,,Other,Not Seperately Reimbusable,142.12,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,158.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,104.5,50,,69.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.5,158.84,
CALCIUM CHLORIDE 10%21-G 100MG,608292,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,92,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
CALCIUM CITRATE + D 250MG,608294,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CALCIUM GLUCONATE 5GM INJ,608296,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,47.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CALCIUM GLUCONATE 500MG TAB,608299,CDM,250,RC,,,Outpatient,500,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
CALDESENE 71G-POWDER,608300,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
CAMPRAL 333MG TAB,608309,CDM,250,RC,,,Outpatient,333,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
CANASA 1000MG SUPP,608310,CDM,250,RC,,,Outpatient,1000,ME,170,119,,,,,,Other,Not Seperately Reimbusable,115.6,68,,92.48,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,85,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,110.5,65,,88.4,Percent of Total Billed Charges,65% of Total Billed Charges,127.5,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,102,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,34.68,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.68,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34,129.2,
CANDIDA 0.1MG-INJ,608314,CDM,250,RC,Y7506,HCPCS,Outpatient,1,ME,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,55.48,
CAPTOPRIL 25MG-TAB,608350,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CAPAZIDE 25/15-TAB,608407,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CABERGOLINE 0.5MG TAB,608415,CDM,250,RC,,,Outpatient,5,ME,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,95.55,65,,76.44,Percent of Total Billed Charges,65% of Total Billed Charges,110.25,75,,88.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,88.2,60,,70.56,Percent of Total Billed Charges,60% of Total Billed Charges,29.99,20.4,,23.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.99,20.4,,23.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.4,20,,23.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.4,111.72,
CARAFATE 1GM TAB,608421,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CAFAFATE 1G/10ML-LIQ,608425,CDM,250,RC,,,Outpatient,110,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,343.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARDEC DROPS-PO,608435,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
CARDEC DM SYRUP PO,608438,CDM,250,RC,,,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,89.05,65,,71.24,Percent of Total Billed Charges,65% of Total Billed Charges,102.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,82.2,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.4,104.12,
CARDENE SR 30MG-TAB,608447,CDM,250,RC,,,Outpatient,30,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CARDIZEM 120MG-TAB,608520,CDM,250,RC,,,Outpatient,120,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
CARDIZEM CD 120MG-CAP,608521,CDM,250,RC,,,Outpatient,120,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
CARDIZEM SR 120-PO,608523,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CARDIZEM CD 240MG-CAP,608524,CDM,250,RC,,,Outpatient,240,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
DILTIAZEM 30MG TAB,608525,CDM,250,RC,,,Outpatient,30,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARDIZEM CD 180MG-CAP,608529,CDM,250,RC,,,Outpatient,180,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
DILTIAZEM 100MG ADV INJ,608530,CDM,250,RC,,,Outpatient,100,ME,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,74.78,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
CARDURA 1MG TAB,608532,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARDURA 2MG TAB,608534,CDM,250,RC,,,Outpatient,2,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,660.9,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
CARDURA 8MG TAB,608535,CDM,250,RC,,,Outpatient,8,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,39.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DILTIAZEM 125MG/25ML INJ,608540,CDM,250,RC,,,Outpatient,125,ME,143,100.1,,,,,,Other,Not Seperately Reimbusable,97.24,68,,77.79,Percent of Total Billed Charges,68% of Total Billed Charges,108.68,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,71.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,92.95,65,,74.36,Percent of Total Billed Charges,65% of Total Billed Charges,107.25,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.6,20,,22.88,Percent of Total Billed Charges,20% of Total Billed Charges,85.8,60,,68.64,Percent of Total Billed Charges,60% of Total Billed Charges,29.17,20.4,,23.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.17,20.4,,23.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,28.6,20,,22.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.6,20,,22.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.6,108.68,
CASCARA AROMATIC 5ML-SUSP,608550,CDM,250,RC,,,Outpatient,5,ML,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
CASODEX 50MG TABLET,608575,CDM,250,RC,,,Outpatient,50,ME,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,59.8,65,,47.84,Percent of Total Billed Charges,65% of Total Billed Charges,69,75,,55.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,55.2,60,,44.16,Percent of Total Billed Charges,60% of Total Billed Charges,18.77,20.4,,15.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.77,20.4,,15.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,20,,14.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.4,69.92,
CASTOR OIL 60CC LIQ,608600,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
DICLOFENAC DR 75MG TAB,608650,CDM,250,RC,,,Outpatient,75,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
DICLOFENAC POTASSIUM 50MG-TAB,608684,CDM,250,RC,,,Outpatient,50,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,149.57,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
CLONIDINE 0.3MG TABLET,608695,CDM,250,RC,,,Outpatient,3,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLONIDINE 0.2MG,608697,CDM,250,RC,,,Outpatient,2,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CLONIDINE HCI 0.1MG TAB,608700,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLONIDINE HCL 0.2MG TAB,608702,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CATAPRES-TTS-2 PATCH 0.2MG,608704,CDM,250,RC,Y7506,HCPCS,Outpatient,202,ME,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
CATAPRES-TTS-1 PATCH 0.1MG,608706,CDM,250,RC,Y7506,HCPCS,Outpatient,101,ME,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,119.17,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
CATAPRES TTS 0.3MG,608708,CDM,250,RC,,,Outpatient,3,ME,155,108.5,,,,,,Other,Not Seperately Reimbusable,105.4,68,,84.32,Percent of Total Billed Charges,68% of Total Billed Charges,117.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,77.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,100.75,65,,80.6,Percent of Total Billed Charges,65% of Total Billed Charges,116.25,75,,93,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,20,,24.8,Percent of Total Billed Charges,20% of Total Billed Charges,93,60,,74.4,Percent of Total Billed Charges,60% of Total Billed Charges,31.62,20.4,,25.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.62,20.4,,25.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,31,20,,24.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,20,,24.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31,117.8,
CLOZAPINE 25MG TAB,608715,CDM,250,RC,,,Outpatient,25,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
CLOZAPINE 100MG TAB,608717,CDM,250,RC,,,Outpatient,100,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
CEBOCAP -CAP,608720,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CECLOR 125MG/5ML 75M-SUSP,608750,CDM,250,RC,,,Outpatient,125,ME,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.25,75,,33,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,33,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11,41.8,
CEFACLOR 250MG/5CC-SUSP,608800,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CEFACLOR 250MG CAPSULE,608801,CDM,250,RC,,,Outpatient,250,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
CECLOR 500MG CAP,608900,CDM,250,RC,,,Outpatient,500,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,94.85,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
CECLOR SUSP 5ML,608910,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,67.49,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CEFOTAN 1GM IV,609270,CDM,250,RC,Y7506,HCPCS,Outpatient,,,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
CEFTIN 250MG TAB,609273,CDM,250,RC,,,Outpatient,250,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,260.83,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
CEFTIN SUSPENSION 125MG/5ML,609274,CDM,250,RC,,,Outpatient,1255,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
CEFTIN 250MG/5ML SUSP 50ML,609275,CDM,250,RC,,,Outpatient,250,ME,241,168.7,,,,,,Other,Not Seperately Reimbusable,163.88,68,,131.1,Percent of Total Billed Charges,68% of Total Billed Charges,183.16,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,120.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,156.65,65,,125.32,Percent of Total Billed Charges,65% of Total Billed Charges,180.75,75,,144.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,144.6,60,,115.68,Percent of Total Billed Charges,60% of Total Billed Charges,49.16,20.4,,39.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.16,20.4,,39.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.2,20,,38.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.2,183.16,
CEFZIL 250MG/5ML SUSP 50ML,609287,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CEFZIL 250MG/5ML-SUSP,609288,CDM,250,RC,,,Outpatient,250,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
CEFZIL 250 MG-PO,609289,CDM,250,RC,,,Outpatient,250,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,251.1,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
CELEBREX 100MG-CAP,609295,CDM,250,RC,,,Outpatient,100,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,193.34,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
CELEBREX 200MG -CAP,609298,CDM,250,RC,,,Outpatient,200,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,241.98,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
CELEXA 20MG-TAB,609310,CDM,250,RC,,,Outpatient,20,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
CELEXA 20 MG-TAB,609311,CDM,250,RC,,,Outpatient,20,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1715.78,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
CELLCEPT 250MG CAP,609312,CDM,250,RC,,,Outpatient,250,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2901.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
CENTRAL-VITE-TAB,609330,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CENTRUM TABLET,609340,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
SORE THROAT LOZENGES-BOX,609352,CDM,250,RC,,,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
CEPHALEXIN 125MG/5ML 100 SUSPE,609361,CDM,250,RC,,,Outpatient,125,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,98.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CEPHALEXIN 125MG/5ML 200 SUSPE,609363,CDM,250,RC,,,Outpatient,125,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CETACAINE SPRAY-TOPICAL,609500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
LIQUI-CHAR 25GRAMS-SUSP,609525,CDM,250,RC,,,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.2,65,,35.36,Percent of Total Billed Charges,65% of Total Billed Charges,51,75,,40.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,40.8,60,,32.64,Percent of Total Billed Charges,60% of Total Billed Charges,13.87,20.4,,11.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.87,20.4,,11.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,20,,10.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.6,51.68,
CHARCOAL ACT. 120ML-SUSP,609526,CDM,250,RC,,,Outpatient,120,ML,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
CHARCOAL PLUS DS-TAB,609527,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
SORE THROAT SPRAY,609650,CDM,250,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ANEMAGEN TAB,610049,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHRONULAC 15ML LIQ,610050,CDM,250,RC,,,Outpatient,15,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,726.56,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHLORAMPHENICOL SODIUM 1GR INJ,610060,CDM,250,RC,J0720,HCPCS,Outpatient,,,51,35.7,,47.29,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
CHLORHEXIDINE GLUCONATE ORAL R,610070,CDM,250,RC,Y7506,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
CONSERTA 18MG TAB,610075,CDM,250,RC,,,Outpatient,18,ME,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,1157.02,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.9,65,,23.92,Percent of Total Billed Charges,65% of Total Billed Charges,34.5,75,,27.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.2,34.96,
CONSTULOSE 10G/15ML-LIQ,610100,CDM,250,RC,,,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5266.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CILOXAN OPTH 0.3% -EYE,610161,CDM,250,RC,Y7506,HCPCS,Outpatient,,,280,196,,,,,,Other,Not Seperately Reimbusable,190.4,68,,152.32,Percent of Total Billed Charges,68% of Total Billed Charges,212.8,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,140,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140,212.8,
CIPRAFLOXCIN 0.3% OPTH SOLN,610170,CDM,250,RC,Y7509,HCPCS,Outpatient,,,252,176.4,,,,,,Other,Not Seperately Reimbusable,171.36,68,,137.09,Percent of Total Billed Charges,68% of Total Billed Charges,191.52,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,126,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,191.52,
CIPRO HC OTIC-BOTTLE,610172,CDM,250,RC,,,Outpatient,,,477,333.9,,,,,,Other,Not Seperately Reimbusable,324.36,68,,259.49,Percent of Total Billed Charges,68% of Total Billed Charges,362.52,76,,373.92,Percent of Total Billed Charges,76% of Total Billed Charges,238.5,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,310.05,65,,248.04,Percent of Total Billed Charges,65% of Total Billed Charges,357.75,75,,286.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.4,20,,76.32,Percent of Total Billed Charges,20% of Total Billed Charges,286.2,60,,228.96,Percent of Total Billed Charges,60% of Total Billed Charges,97.31,20.4,,77.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,97.31,20.4,,77.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,95.4,20,,76.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.4,20,,76.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,95.4,362.52,
CIPRO 400MG/40ML-INJ,610176,CDM,250,RC,J0744,HCPCS,Outpatient,,,154,107.8,,2.13,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,105.18,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
CIPRO 500MG-CAP,610177,CDM,250,RC,,,Outpatient,500,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,56.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
CIPRO 200MG/20ML INJ,610179,CDM,250,RC,J0744,HCPCS,Outpatient,200,ME,68,47.6,,2.13,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
MAGNESIUM CITRATE 10OZ-LIQ,610200,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
CITRUCEL 16 OZ PWD,610205,CDM,250,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,164.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
CITRUCEL 160 -POWDER,610210,CDM,250,RC,Y7506,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
CLARINEX 5MG,610212,CDM,250,RC,,,Outpatient,5,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
CLARITIN 10MG-TAB,610213,CDM,250,RC,,,Outpatient,10,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
CLARITIN D 12 HR 5MG/120MG-PO,610214,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLARITIN D 24 HR 10MG/240MG SL,610215,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLARITIN SYRUP 10MG-LIQ,610220,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLEOCIN 75MG/5ML INJ,610229,CDM,250,RC,,,Outpatient,755,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CLINDAMYCIN 150MG -CAP,610230,CDM,250,RC,,,Outpatient,150,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLINDAMYCIN 1% GEL,610234,CDM,250,RC,Y7506,HCPCS,Outpatient,,,346,242.2,,,,,,Other,Not Seperately Reimbusable,235.28,68,,188.22,Percent of Total Billed Charges,68% of Total Billed Charges,262.96,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,173,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173,262.96,
CLEOCIN VAGINAL OVULE 100MG SU,610235,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,102,71.4,,,,,,Other,Not Seperately Reimbusable,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
CLINDAMYCIN 300MG VL INJ,610236,CDM,250,RC,,,Outpatient,300,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
CLEOCIN VAG CREAM 2%,610240,CDM,250,RC,Y7506,HCPCS,Outpatient,,,290,203,,,,,,Other,Not Seperately Reimbusable,197.2,68,,157.76,Percent of Total Billed Charges,68% of Total Billed Charges,220.4,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,145,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145,220.4,
CLINIMIX 5/15 1000ML INJ,610245,CDM,250,RC,,,Outpatient,1000,ML,550,385,,,,,,Other,Not Seperately Reimbusable,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,418,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,275,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,357.5,65,,286,Percent of Total Billed Charges,65% of Total Billed Charges,412.5,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,112.2,20.4,,89.76,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.2,20.4,,89.76,Percent of Total Billed Charges,20.4% of Total Billed Charges,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,418,
CLIMARA 0.05MG/DAY-PATCH,610246,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CLINIMIX 5/20 1000ML INJ,610250,CDM,250,RC,,,Outpatient,1000,ML,550,385,,,,,,Other,Not Seperately Reimbusable,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,418,76,,119.78,Percent of Total Billed Charges,76% of Total Billed Charges,275,50,,47.2,Percent of Total Billed Charges,50% of Total Billed Charges,357.5,65,,286,Percent of Total Billed Charges,65% of Total Billed Charges,412.5,75,,330,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,330,60,,264,Percent of Total Billed Charges,60% of Total Billed Charges,112.2,20.4,,89.76,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,112.2,20.4,,89.76,Percent of Total Billed Charges,20.4% of Total Billed Charges,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,20,,88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110,418,
CLOBETASOL CREAM,610410,CDM,250,RC,,,Outpatient,,,132,92.4,,,,,,Other,Not Seperately Reimbusable,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,100.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,66,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.8,65,,68.64,Percent of Total Billed Charges,65% of Total Billed Charges,99,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,79.2,60,,63.36,Percent of Total Billed Charges,60% of Total Billed Charges,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.93,20.4,,21.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.4,20,,21.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.4,100.32,
CLOBETASOL PROPIONATE 15G GEL,610412,CDM,250,RC,Y7506,HCPCS,Outpatient,,,140,98,,,,,,Other,Not Seperately Reimbusable,95.2,68,,76.16,Percent of Total Billed Charges,68% of Total Billed Charges,106.4,76,,68.7,Percent of Total Billed Charges,76% of Total Billed Charges,70,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,106.4,
CLOBETASOL PROPIONATE 60G GEL,610414,CDM,250,RC,Y7506,HCPCS,Outpatient,,,328,229.6,,,,,,Other,Not Seperately Reimbusable,223.04,68,,178.43,Percent of Total Billed Charges,68% of Total Billed Charges,249.28,76,,59.58,Percent of Total Billed Charges,76% of Total Billed Charges,164,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164,249.28,
CLOMIPRAMINE HCL 25MG CAPSULE,610420,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLORAZEPATE DIPOTASSIUM 7.5MG,610439,CDM,250,RC,,,Outpatient,75,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,100.32,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
COCAINE 4% 4ML,610441,CDM,250,RC,Y7506,HCPCS,Outpatient,44,ML,129,90.3,,,,,,Other,Not Seperately Reimbusable,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,98.04,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,64.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.5,98.04,
CODEINE SULFATE 30MG-TAB,610450,CDM,250,RC,,,Outpatient,30,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DOCUSATE SODIUM 100MG CAP,610500,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COLACE LIQ. 30ML BOT LIQ,610503,CDM,250,RC,,,Outpatient,30,ML,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
COLACE 100MG/25ML LIQ,610505,CDM,250,RC,,,Outpatient,100,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
COLACE SYRUP 240ML,610507,CDM,250,RC,,,Outpatient,240,ML,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.35,65,,20.28,Percent of Total Billed Charges,65% of Total Billed Charges,29.25,75,,23.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,23.4,60,,18.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.96,20.4,,6.37,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.96,20.4,,6.37,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.8,29.64,
COLCHICINE 1MG/2ML INJECTION,610523,CDM,250,RC,J0760,HCPCS,Outpatient,12,ME,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
COLCHICINE 0.6MG TAB,610525,CDM,250,RC,,,Outpatient,6,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COLESTID 1GM TABLET,610530,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROBENECID/COLCHIDINE 500MG/0.,610550,CDM,250,RC,,,Outpatient,5000,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COLLAGENASE SANTYL OINTMENT,610559,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
COMBIVENT INHALER,610675,CDM,250,RC,Y7506,HCPCS,Outpatient,,,389,272.3,,,,,,Other,Not Seperately Reimbusable,264.52,68,,211.62,Percent of Total Billed Charges,68% of Total Billed Charges,295.64,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,194.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.5,295.64,
PROCHLORPERAZINE 5MG TAB,610750,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COMPAZINE 25MG SUPP,610800,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
COMPAZINE 10MG TAB,610850,CDM,250,RC,,,Outpatient,10,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
COREG 12.5 TABLET,610902,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
COREG CR 10MG CAP,610905,CDM,250,RC,,,Outpatient,10,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
COREG CR 20MG CAP,610906,CDM,250,RC,,,Outpatient,20,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
COREG CR 40MG CAP,610907,CDM,250,RC,,,Outpatient,40,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,1352.8,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
COREG 80MG CAP,610908,CDM,250,RC,,,Outpatient,80,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,103.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
CORTENEMA 100MG/60ML ENEMA,610910,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
CORGARD 20MG TABLET,610922,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,65.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CORDARONE 200MG-TAB,610935,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COREG 3.125MG-TAB,610942,CDM,250,RC,,,Outpatient,3125,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
COREG 6.25MG TABLET,610945,CDM,250,RC,,,Outpatient,625,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
COREG 25MG TABLET,610947,CDM,250,RC,,,Outpatient,25,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
CORGARD 40MG TAB,610950,CDM,250,RC,,,Outpatient,40,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CORRECTOL 5MG -TAB,610977,CDM,250,RC,,,Outpatient,5,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
NEOM. POLYMIXIN B HYDCORT-EAR,611150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,72.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CORTEF 10MG TABLET,611170,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,151.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CORTISPORIN 7.5ML-EAR,611200,CDM,250,RC,Y7506,HCPCS,Outpatient,75,ML,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,242.44,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,159.5,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,242.44,
COSOPT SOLUTION-EYE,611384,CDM,250,RC,Y7506,HCPCS,Outpatient,,,228,159.6,,,,,,Other,Not Seperately Reimbusable,155.04,68,,124.03,Percent of Total Billed Charges,68% of Total Billed Charges,173.28,76,,4409.82,Percent of Total Billed Charges,76% of Total Billed Charges,114,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,173.28,
COSOPT OCUMETER PLUS .5%-2%,611386,CDM,250,RC,,,Outpatient,,,281,196.7,,,,,,Other,Not Seperately Reimbusable,191.08,68,,152.86,Percent of Total Billed Charges,68% of Total Billed Charges,213.56,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,140.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,182.65,65,,146.12,Percent of Total Billed Charges,65% of Total Billed Charges,210.75,75,,168.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.2,20,,44.96,Percent of Total Billed Charges,20% of Total Billed Charges,168.6,60,,134.88,Percent of Total Billed Charges,60% of Total Billed Charges,57.32,20.4,,45.86,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.32,20.4,,45.86,Percent of Total Billed Charges,20.4% of Total Billed Charges,56.2,20,,44.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.2,20,,44.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,56.2,213.56,
COUMADIN 1MG-TAB,611390,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COUMADIN 2MG TAB,611398,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COUMADIN 2.5MG TAB,611400,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,149.57,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,62.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COUMADIN 3MG,611425,CDM,250,RC,,,Outpatient,3,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,152,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
COUMADIN 4MG TAB,611427,CDM,250,RC,,,Outpatient,4,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
COUMADIN 5MG TAB,611450,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,68.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CRESTOR 10MG TAB,611490,CDM,250,RC,,,Outpatient,10,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
COUMADIN 10MG TAB,611550,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
COVERA HS 240MG-TAB,611553,CDM,250,RC,,,Outpatient,240,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
COZAAR 25MG-TAB,611554,CDM,250,RC,,,Outpatient,25,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
CRITIC-OINT,611565,CDM,250,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
CROMOLYN 4% OPTH,611575,CDM,250,RC,Y7506,HCPCS,Outpatient,,,149,104.3,,,,,,Other,Not Seperately Reimbusable,101.32,68,,81.06,Percent of Total Billed Charges,68% of Total Billed Charges,113.24,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,74.5,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,113.24,
CUTIVATE CREAM 0.05% CREAM,611586,CDM,250,RC,Y7506,HCPCS,Outpatient,,,2136,1495.2,,,,,,Other,Not Seperately Reimbusable,1452.48,68,,1161.98,Percent of Total Billed Charges,68% of Total Billed Charges,1623.36,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,1068,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1068,1623.36,
CYCLOGYL 1% DROPS-EYE,611618,CDM,250,RC,Y7506,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
CYLERT 75MG TABLET,611630,CDM,250,RC,,,Outpatient,75,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
CYANOCOBALAMIN 1000MCG TAB,611650,CDM,250,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
CYMBALTA 30MG TAB,611750,CDM,250,RC,,,Outpatient,30,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
CYTOSPAZ 0.15MG TAB,611790,CDM,250,RC,,,Outpatient,15,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,86.34,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CYTOTEC 25MCG-TAB,611793,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
CYTOTEC 100MCG-TAB,611797,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
D5 1/2 W 20 MEQ KCL  1000ML,611900,CDM,250,RC,Y7506,HCPCS,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5 1/2 W 40 MEQ KCL   1000ML,611901,CDM,250,RC,Y7506,HCPCS,Outpatient,1000,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,250.5,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DACRIOSE OPTH 30ML DROPS-EYE,611951,CDM,250,RC,Y7506,HCPCS,Outpatient,30,ML,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
DACRIOSE OPTH IRRIGATION 120ML,611952,CDM,250,RC,Y7506,HCPCS,Outpatient,120,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DALIRESP 500MCG TAB,612000,CDM,250,RC,,,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
DANTRIUM 25MG CAP,612100,CDM,250,RC,,,Outpatient,25,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
PROPOXYPHENE NAPSYLATE/AP 100M,612250,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DAPSONE 25MG TAB,612445,CDM,250,RC,,,Outpatient,25,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,53.5,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
DAYPRO 600MG-TAB,612465,CDM,250,RC,,,Outpatient,600,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
DEBROX 6.5%,612505,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DECADRON 4MG/ML SYR,612550,CDM,250,RC,J1100,HCPCS,Outpatient,4,ME,25,17.5,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
DECADRON OPT 5ML DRP-EYE,612700,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
DECADRON 0.05% OPH O -EYE,612705,CDM,250,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
DECOFED 30MG/5ML,612750,CDM,250,RC,,,Outpatient,305,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,49.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DEXAMETHASONE 4MG TABLET,612800,CDM,250,RC,,,Outpatient,4,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DELSYM 83ML PO,613260,CDM,250,RC,,,Outpatient,83,ML,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,71.74,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36.48,
DEMADEX 100MG TAB,613275,CDM,250,RC,,,Outpatient,100,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,64.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
DEMECLOCYCLINE 150MG TAB,613290,CDM,250,RC,,,Outpatient,150,ME,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36.48,
DEMEROL SYRUP 50MG SYRUP-LIQ,613293,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MEPERIDINE 50MG -PO,613300,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
"HEMEROL 75,25,100ML INJ-DO NOT",613350,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ML,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
VALPROIC ACID 250MG -LIQ,613378,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DEPAKENE 250MG/5ML SYRUP,613380,CDM,250,RC,,,Outpatient,250,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
DEPAKOTE 250MG ER,613382,CDM,250,RC,,,Outpatient,250,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
DEPAKOTE SPRINKLE 125MG -CAP,613384,CDM,250,RC,,,Outpatient,125,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,154,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
DEPAKOTE ER 500 MG TAB,613385,CDM,250,RC,,,Outpatient,500,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
DEPAKOTE DR 250MG TAB,613387,CDM,250,RC,,,Outpatient,250,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
DEPAKOTE DR 500MG TAB,613389,CDM,250,RC,,,Outpatient,500,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
DEPO-ESTRADIOL 5MG/ML-INJ,613400,CDM,250,RC,J1000,HCPCS,Outpatient,5,ME,162,113.4,,39.33,100,,,fee schedule,100% Aetna Market fee schedule,110.16,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,123.12,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,81,50,,395.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81,123.12,
DEPO-MEDROL 40MG/ML-INJ,613450,CDM,250,RC,,,Outpatient,40,ME,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
DEPOTESTADIOL 100MG-INJ,613558,CDM,250,RC,J1071,HCPCS,Outpatient,100,ME,32,22.4,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,156,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
DEPO-TESTOSTRN 200MG-INJ,613600,CDM,250,RC,J1071,HCPCS,Outpatient,200,ME,65,45.5,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,49.4,
DEPO TESTOSTERONE 200MG/ML INJ,613601,CDM,250,RC,Y7506,HCPCS,Outpatient,200,ME,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
TRAVATAN 0.004% OPTH SOLUTION,613650,CDM,250,RC,Y7506,HCPCS,Outpatient,,,360,252,,,,,,Other,Not Seperately Reimbusable,244.8,68,,195.84,Percent of Total Billed Charges,68% of Total Billed Charges,273.6,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,180,50,,258,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,273.6,
DETROL 1MG -TAB,613720,CDM,250,RC,,,Outpatient,1,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
DESIPRAMINE 10MG TAB,613725,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DETROL LA 2MG CAP,613730,CDM,250,RC,,,Outpatient,2,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
DESIPRAMINE 75MG TAB,613745,CDM,250,RC,,,Outpatient,75,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DESITIN 1OZ OINT,613750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
TRAZODONE 50MG-PO,613760,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,157.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TRAZODONE 100MG TAB,613775,CDM,250,RC,,,Outpatient,100,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
TRAZADONE 150MG TAB,613780,CDM,250,RC,,,Outpatient,150,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,99.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DEXTROSE 5% PAB 100ML-I.V.,613790,CDM,250,RC,Y7507,HCPCS,Outpatient,100,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DESVENLAFAXINE 25MG TAB,613791,CDM,250,RC,,,Outpatient,25,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
DEXTROSE 10% 250ML,613792,CDM,250,RC,,,Outpatient,50,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
DEXTROSE 30% I.V. SOLUTION,613798,CDM,250,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
DEXTROSE 50% 50CC INJ,613800,CDM,250,RC,,,Outpatient,,,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,39,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,31.2,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,39.52,
DEXTROSTATE 20MG TABLET,613805,CDM,250,RC,,,Outpatient,20,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
DESMOPRESSIN 0.2MG TAB,613825,CDM,250,RC,,,Outpatient,2,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,110.66,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
DESMOPRESSIN NASAL 0.1%,613850,CDM,250,RC,Y7506,HCPCS,Outpatient,,,693,485.1,,,,,,Other,Not Seperately Reimbusable,471.24,68,,376.99,Percent of Total Billed Charges,68% of Total Billed Charges,526.68,76,,230.43,Percent of Total Billed Charges,76% of Total Billed Charges,346.5,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346.5,526.68,
DESOXIMETASONE CREAM 0.05%,613900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,268,187.6,,,,,,Other,Not Seperately Reimbusable,182.24,68,,145.79,Percent of Total Billed Charges,68% of Total Billed Charges,203.68,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,134,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,203.68,
DIABETA 2.5MG TAB,613930,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLYBURIDE 5MG TABLET,613940,CDM,250,RC,,,Outpatient,5,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
ACETAZOLAMIDE 250MG-TAB,614000,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DICEL CD LIQUID 5ML ORAL,614050,CDM,250,RC,,,Outpatient,5,ML,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
DICLOXACILLIN 500MG CAPSULE,614100,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DICYCLOMINE HCL 10MG TABLET,614150,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,94.85,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIFLUCAN ORAL SUSP 40MG,614234,CDM,250,RC,,,Outpatient,40,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
DIFLUCAN 100MG-TAB,614235,CDM,250,RC,,,Outpatient,100,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
DIFLUCAN 400MG/200ML INJ,614237,CDM,250,RC,J1450,HCPCS,Outpatient,,,702,491.4,,3.08,100,,,fee schedule,100% Aetna Market fee schedule,477.36,68,,381.89,Percent of Total Billed Charges,68% of Total Billed Charges,533.52,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,351,50,,22.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351,533.52,
DIFLUCAN 10MG/ML SUSPENSION,614238,CDM,250,RC,,,Outpatient,10,ME,192,134.4,,,,,,Other,Not Seperately Reimbusable,130.56,68,,104.45,Percent of Total Billed Charges,68% of Total Billed Charges,145.92,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,96,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,124.8,65,,99.84,Percent of Total Billed Charges,65% of Total Billed Charges,144,75,,115.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.4,20,,30.72,Percent of Total Billed Charges,20% of Total Billed Charges,115.2,60,,92.16,Percent of Total Billed Charges,60% of Total Billed Charges,39.17,20.4,,31.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.17,20.4,,31.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,38.4,20,,30.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.4,20,,30.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.4,145.92,
DIFLUCAN 150MG TAB,614239,CDM,250,RC,,,Outpatient,150,ME,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
FLUDROCORTISONE 0.1MG TAB,614245,CDM,250,RC,,,Outpatient,1,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
DILANTIN 100MG CAP,614350,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,871.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DILANTIN SUSP 125/5 237ML ORAL,614450,CDM,250,RC,,,Outpatient,137,ML,165,115.5,,,,,,Other,Not Seperately Reimbusable,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,125.4,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,82.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,65,,85.8,Percent of Total Billed Charges,65% of Total Billed Charges,123.75,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,99,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33,125.4,
PHENYTOIN 250MG/5ML,614455,CDM,250,RC,Y7506,HCPCS,Outpatient,250,ME,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
DILANTIN INFATABS 50MG TABLET,614460,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DILATRATE SR 40MG-TAB,614470,CDM,250,RC,,,Outpatient,40,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
DILAUDID 2MG TAB,614500,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIMETAPP ELIXIR 5ML-LIQ,614850,CDM,250,RC,,,Outpatient,5,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
DOCUSATE NQ 20MG/5ML,614855,CDM,250,RC,,,Outpatient,205,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIOVAN 80MG TAB,614863,CDM,250,RC,,,Outpatient,80,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
DIOVAN HCT 80/12.5MG TAB,614885,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
DIOVAN HCT 160/12.5MG TABLET,614890,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
DIOVAN 160MG TAB,614895,CDM,250,RC,,,Outpatient,160,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
DIPRIVAN 50MG INJ,614900,CDM,250,RC,,,Outpatient,50,ME,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.55,65,,45.24,Percent of Total Billed Charges,65% of Total Billed Charges,65.25,75,,52.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,52.2,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,17.75,20.4,,14.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.75,20.4,,14.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.4,66.12,
DIPYRIDAMOLE 10MG/2ML-INJ,614956,CDM,250,RC,J1245,HCPCS,Outpatient,102,ME,159,111.3,,4.09,100,,,fee schedule,100% Aetna Market fee schedule,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,120.84,
OXYBUTYNIN CHLORIDE 5MG-TAB,615000,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DITROPAN XL 5MG-TAB,615002,CDM,250,RC,,,Outpatient,5,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
AMICAR INJ 250MG,615003,CDM,250,RC,J3490,HCPCS,Outpatient,250,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,64,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
DOCUSATE SOD & CASA 100MG/10ML,615200,CDM,250,RC,,,Outpatient,100,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
DOMEBORO TAB 604MG/878MG,615250,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DONNATAL ELIX 5ML-LIQ,615500,CDM,250,RC,,,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DOPRAM 400MG INJ,615650,CDM,250,RC,Y7506,HCPCS,Outpatient,400,ME,519,363.3,,,,,,Other,Not Seperately Reimbusable,352.92,68,,282.34,Percent of Total Billed Charges,68% of Total Billed Charges,394.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,259.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.5,394.44,
BISACODYL 10MG SUPP,615950,CDM,250,RC,Y7506,HCPCS,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BISACODYL E.C. 5MG TAB,616000,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DURAGESIC PATCH 50MCG,616061,CDM,250,RC,Y7506,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,106.76,68,,85.41,Percent of Total Billed Charges,68% of Total Billed Charges,119.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,78.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,119.32,
DURAGESIC 25MCG/HR TOPICAL,616062,CDM,250,RC,Y7506,HCPCS,Outpatient,,,96,67.2,,,,,,Other,Not Seperately Reimbusable,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,97.89,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,85.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
DURAGESIC 75MCG/HR TOPICAL,616063,CDM,250,RC,Y7506,HCPCS,Outpatient,,,239,167.3,,,,,,Other,Not Seperately Reimbusable,162.52,68,,130.02,Percent of Total Billed Charges,68% of Total Billed Charges,181.64,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,119.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.5,181.64,
DURAGESIC 100MCG/HR TOPICAL,616064,CDM,250,RC,Y7506,HCPCS,Outpatient,,,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
CEFADROXIL 500MG CAP,616100,CDM,250,RC,,,Outpatient,500,ME,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,21,75,,16.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.6,21.28,
DURICEF 125MG/5ML-SUSP,616101,CDM,250,RC,,,Outpatient,1255,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
DURICEF 250MG/5ML-SUSP,616102,CDM,250,RC,,,Outpatient,250,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,945.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
DURICEF 500MG SUSP,616103,CDM,250,RC,,,Outpatient,500,ME,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,1260.4,Percent of Total Billed Charges,50% of Total Billed Charges,100.1,65,,80.08,Percent of Total Billed Charges,65% of Total Billed Charges,115.5,75,,92.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,20,,24.64,Percent of Total Billed Charges,20% of Total Billed Charges,92.4,60,,73.92,Percent of Total Billed Charges,60% of Total Billed Charges,31.42,20.4,,25.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.42,20.4,,25.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,30.8,20,,24.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.8,20,,24.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.8,117.04,
DURICEF SUSP 5ML,616112,CDM,250,RC,,,Outpatient,5,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,234.08,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
DYNEX TABLET,616120,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
BISOPROLOL HCL 10/6.25MG TAB,616250,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
EC-NAPROSYN 375MG-TAB,616313,CDM,250,RC,,,Outpatient,375,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ECONOPRED PLUS 1% DROPS-EYE,616320,CDM,250,RC,Y7506,HCPCS,Outpatient,,,149,104.3,,,,,,Other,Not Seperately Reimbusable,101.32,68,,81.06,Percent of Total Billed Charges,68% of Total Billed Charges,113.24,76,,601.31,Percent of Total Billed Charges,76% of Total Billed Charges,74.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,113.24,
EC-NAPROSYN 500MG-TAB,616330,CDM,250,RC,,,Outpatient,500,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ASPIRIN ENTERIC COATED 81MG-TA,616336,CDM,250,RC,,,Outpatient,81,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
EFFEXOR 75MG TAB,616369,CDM,250,RC,,,Outpatient,75,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
EFFEXOR 37.5MG TAB,616370,CDM,250,RC,,,Outpatient,375,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,237.12,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
EFFEXOR XR 37.5MG-CAP,616371,CDM,250,RC,,,Outpatient,375,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,354.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
EFFEXOR XR 150MG CAPSULE,616372,CDM,250,RC,,,Outpatient,150,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
EFFEXOR XR 75MG -CAP,616373,CDM,250,RC,,,Outpatient,75,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,392.16,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
EFUDEX 5% 25G CREAM,616377,CDM,250,RC,Y7506,HCPCS,Outpatient,,,357,249.9,,,,,,Other,Not Seperately Reimbusable,242.76,68,,194.21,Percent of Total Billed Charges,68% of Total Billed Charges,271.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,178.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.5,271.32,
ENTACAPONE 200MG TAB,616550,CDM,250,RC,,,Outpatient,200,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,68.7,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
AMITIZA 8MCG CAP,616590,CDM,250,RC,,,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
AMITRIPTYLINE 10MG-TAB,616600,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMITRIPTYLINE 25MG-TAB,616625,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMITRIPTYLINE 50MG TAB,616650,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMITRIPTYLINE 100MG-TAB,616725,CDM,250,RC,,,Outpatient,100,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,49.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ELIDEL 1% 30GM CREAM,616890,CDM,250,RC,Y7506,HCPCS,Outpatient,,,340,238,,,,,,Other,Not Seperately Reimbusable,231.2,68,,184.96,Percent of Total Billed Charges,68% of Total Billed Charges,258.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,170,50,,750,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170,258.4,
ELIQUIS 2.5MG TAB,616900,CDM,250,RC,,,Outpatient,25,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
ELIQUIS 5MG TAB,616905,CDM,250,RC,,,Outpatient,5,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
ELOCON CREAM 0.1%,616907,CDM,250,RC,Y7506,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,118.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
EMLA CREAM,616940,CDM,250,RC,Y7506,HCPCS,Outpatient,,,23,16.1,,,,,,Other,Not Seperately Reimbusable,15.64,68,,12.51,Percent of Total Billed Charges,68% of Total Billed Charges,17.48,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,11.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.5,17.48,
EMETROL,616960,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
EMLA CREAM,616963,CDM,250,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,408,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
EMPTY EVACUATED CONT.-250ML BO,616970,CDM,250,RC,Y7507,HCPCS,Outpatient,50,ML,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
ENALAPRIL 1.25MG TAB,616989,CDM,250,RC,,,Outpatient,125,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,162.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ENALAPRILATE 2.5MG TAB,616990,CDM,250,RC,,,Outpatient,25,ME,71,49.7,,,,,,Other,Not Seperately Reimbusable,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,217.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.15,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,53.25,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,42.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.2,53.96,
ENTOCORT EC CAP,616995,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
PHENYLFENESIN LA 75/400MG-TAB,617151,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
EPHEDRINE 25MG/ML INJ,617230,CDM,250,RC,W1051,HCPCS,Outpatient,25,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
EPHEDRINE 50MG/ML-INJ,617231,CDM,250,RC,,,Outpatient,50,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,2928.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
EPHDRINE SUL 25MG C,617232,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
EPINEPHRINE ABBOJECT 1:10000 1,617250,CDM,250,RC,J1071,HCPCS,Outpatient,,,24,16.8,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
EPSOM SALT 1 POUND-PO,617310,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,297.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MEPROBAMATE 200MG-TAB,617400,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ERYLHROMYCIN 250MG-TAB,617475,CDM,250,RC,,,Outpatient,250,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
ERYPED 400MG SUSP,617487,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1324.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1091.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ERYPED 400MG/5ML SUSPENSION,617488,CDM,250,RC,,,Outpatient,4005,ME,1806,1264.2,,,,,,Other,Not Seperately Reimbusable,1228.08,68,,982.46,Percent of Total Billed Charges,68% of Total Billed Charges,1372.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,903,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,1173.9,65,,939.12,Percent of Total Billed Charges,65% of Total Billed Charges,1354.5,75,,1083.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.2,20,,288.96,Percent of Total Billed Charges,20% of Total Billed Charges,1083.6,60,,866.88,Percent of Total Billed Charges,60% of Total Billed Charges,368.42,20.4,,294.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,368.42,20.4,,294.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,361.2,20,,288.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.2,20,,288.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.2,1372.56,
ERYPED DROPS 200MG-LIQ,617489,CDM,250,RC,,,Outpatient,200,ME,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
ERYTHROMYCIN 3.5GM,617499,CDM,250,RC,,,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,653.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,21,75,,16.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.6,21.28,
ERYTHROMYCIN 250MG TAB,617500,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,653.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
EES 400 400MG-TAB,617550,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ERYTH.ETHYLSUCCINATE 200MG/600,617555,CDM,250,RC,,,Outpatient,200,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
ERYTHROMYCIN 400MG/5M-SUSP,617650,CDM,250,RC,,,Outpatient,4005,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,80.26,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
ERYTHROMYCIN 250MG IV,617802,CDM,250,RC,Y7506,HCPCS,Outpatient,250,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ESTRACE 0.01% CREAM,617865,CDM,250,RC,Y7506,HCPCS,Outpatient,,,225,157.5,,,,,,Other,Not Seperately Reimbusable,153,68,,122.4,Percent of Total Billed Charges,68% of Total Billed Charges,171,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,112.5,50,,39.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,171,
ESMOLOL HCL/NACL 250MG/ML INJ,617867,CDM,250,RC,Y7506,HCPCS,Outpatient,250,ME,66,46.2,,,,,,Other,Not Seperately Reimbusable,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
ESTRACE 1MG-TAB,617870,CDM,250,RC,,,Outpatient,1,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ESTRADERM 0.05 PATCH,617876,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
ESTRADIOL 1MG TABLET,617877,CDM,250,RC,,,Outpatient,1,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2322.56,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ESTROPIPATE 1.5MG TABLET,617878,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ESTRATEST 1.25/2.5MG TAB,617879,CDM,250,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
ETODOLAC 400MG-TAB,617890,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ETHEZYME 830 OINT,617900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,262,183.4,,,,,,Other,Not Seperately Reimbusable,178.16,68,,142.53,Percent of Total Billed Charges,68% of Total Billed Charges,199.12,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,131,50,,39.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131,199.12,
ETHOSUXIMIDE 250MG CAP,617910,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,351.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ETHYL CHLORIDE-TOPICAL,617914,CDM,250,RC,Y7506,HCPCS,Outpatient,,,99,69.3,,,,,,Other,Not Seperately Reimbusable,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,75.24,76,,102.14,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.5,75.24,
EVEERIN CREAM,617916,CDM,250,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,30687.58,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
EVISTA 60MG TABLET,617918,CDM,250,RC,,,Outpatient,60,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
EXELON 1.5MG TABLET,617919,CDM,250,RC,,,Outpatient,15,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
EXELON 4.6MG/24HR PATCH,617925,CDM,250,RC,Y7506,HCPCS,Outpatient,4624,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
EXTENDED PHENYTOIN SOD. 100MG,617930,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,222.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
EUCERIN OINT,617940,CDM,250,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,189.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
FAMVIR 250MG TAB,617945,CDM,250,RC,,,Outpatient,250,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
FAMOTIDINE 20MG,617949,CDM,250,RC,,,Outpatient,20,ME,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,52.65,65,,42.12,Percent of Total Billed Charges,65% of Total Billed Charges,60.75,75,,48.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,48.6,60,,38.88,Percent of Total Billed Charges,60% of Total Billed Charges,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.52,20.4,,13.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,20,,12.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.2,61.56,
FAMVIR 500MG TAB,617950,CDM,250,RC,,,Outpatient,500,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
PIROXICAM 10MG CAP,617990,CDM,250,RC,,,Outpatient,10,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
PIROXICAM 20MG TAB,617995,CDM,250,RC,,,Outpatient,20,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,130.11,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
FERROUS SULFATE 220MG/5ML -LIQ,618150,CDM,250,RC,,,Outpatient,2205,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,58,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FER-IRON DROPS 75MG-PO,618203,CDM,250,RC,,,Outpatient,75,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,433.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FERROUS SULFATE 300MG TAB,618214,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,98,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FE-TINIC 150MG TAB,618220,CDM,250,RC,,,Outpatient,150,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
BUTALBITAL/ACETAM/CAFFEIN 50/3,618234,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1436.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FLUOR-I-STRIP 9MG-EYE,618236,CDM,250,RC,Y7506,HCPCS,Outpatient,9,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1915.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,23.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FIBER-LAX-TAB,618240,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FIDAXOMICIN 200 MG TAB,618241,CDM,250,RC,,,Outpatient,200,ME,800,560,,,,,,Other,Not Seperately Reimbusable,544,68,,435.2,Percent of Total Billed Charges,68% of Total Billed Charges,608,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,400,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,520,65,,416,Percent of Total Billed Charges,65% of Total Billed Charges,600,75,,480,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,20,,128,Percent of Total Billed Charges,20% of Total Billed Charges,480,60,,384,Percent of Total Billed Charges,60% of Total Billed Charges,163.2,20.4,,130.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,163.2,20.4,,130.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,160,20,,128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160,20,,128,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,160,608,
FIORNAL W/CODEINE TAB,618250,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
FIORNAL 50MG/325MG/40MG-TAB,618300,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
METRONIDAZOLE 500MG/100CC -INJ,618348,CDM,250,RC,,,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
METRONIDAZOLE 250MG-TAB,618350,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FLAREX 0.1% OPTH DROPS,618375,CDM,250,RC,Y7506,HCPCS,Outpatient,,,178,124.6,,,,,,Other,Not Seperately Reimbusable,121.04,68,,96.83,Percent of Total Billed Charges,68% of Total Billed Charges,135.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,89,50,,13.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89,135.28,
FLECAINIDE 50MG TAB,618395,CDM,250,RC,,,Outpatient,50,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
FLEET PHOSPHSODA 60ML-LIQ,618400,CDM,250,RC,Y7506,HCPCS,Outpatient,60,ML,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
CYCLOBENZAPRINE HCL 10MG,618450,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,538.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FLOMAX 0.4MG-CAP,618456,CDM,250,RC,,,Outpatient,4,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,138.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
FLONASE 50MCG/SPRAY,618464,CDM,250,RC,Y7506,HCPCS,Outpatient,,,394,275.8,,,,,,Other,Not Seperately Reimbusable,267.92,68,,214.34,Percent of Total Billed Charges,68% of Total Billed Charges,299.44,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,197,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197,299.44,
FLOVENT INHALATION 44MCG,618478,CDM,250,RC,Y7506,HCPCS,Outpatient,,,380,266,,,,,,Other,Not Seperately Reimbusable,258.4,68,,206.72,Percent of Total Billed Charges,68% of Total Billed Charges,288.8,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,190,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190,288.8,
FLOVENT 110MCG INHALER,618479,CDM,250,RC,Y7506,HCPCS,Outpatient,,,510,357,,,,,,Other,Not Seperately Reimbusable,346.8,68,,277.44,Percent of Total Billed Charges,68% of Total Billed Charges,387.6,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,255,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,387.6,
FLOVENT INHALATION 220MCG,618480,CDM,250,RC,Y7506,HCPCS,Outpatient,,,791,553.7,,,,,,Other,Not Seperately Reimbusable,537.88,68,,430.3,Percent of Total Billed Charges,68% of Total Billed Charges,601.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,395.5,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.5,601.16,
FLOXIN OTIC .3% EAR DROPS,618490,CDM,250,RC,Y7506,HCPCS,Outpatient,,,326,228.2,,,,,,Other,Not Seperately Reimbusable,221.68,68,,177.34,Percent of Total Billed Charges,68% of Total Billed Charges,247.76,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,163,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163,247.76,
FLOXIN OPHTHALMIC DROPS-BOTTLE,618495,CDM,250,RC,Y7506,HCPCS,Outpatient,,,281,196.7,,,,,,Other,Not Seperately Reimbusable,191.08,68,,152.86,Percent of Total Billed Charges,68% of Total Billed Charges,213.56,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,140.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.5,213.56,
FLUOTHANE/15 MIN.,618550,CDM,250,RC,Y7509,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
FLUOR-OP 5ML DROPS-PO,618574,CDM,250,RC,,,Outpatient,5,ML,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,75.39,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,65,,46.8,Percent of Total Billed Charges,65% of Total Billed Charges,67.5,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,18.36,20.4,,14.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.36,20.4,,14.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18,68.4,
FLUPHENAZINE 2.5MG INJ,618577,CDM,250,RC,,,Outpatient,25,ME,358,250.6,,,,,,Other,Not Seperately Reimbusable,243.44,68,,194.75,Percent of Total Billed Charges,68% of Total Billed Charges,272.08,76,,1140,Percent of Total Billed Charges,76% of Total Billed Charges,179,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,232.7,65,,186.16,Percent of Total Billed Charges,65% of Total Billed Charges,268.5,75,,214.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,214.8,60,,171.84,Percent of Total Billed Charges,60% of Total Billed Charges,73.03,20.4,,58.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,73.03,20.4,,58.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.6,20,,57.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.6,272.08,
FLUPHENAZINE HCL 1MG-TAB,618578,CDM,250,RC,,,Outpatient,1,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
FLUPHENAZINE 5MG TAB,618579,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FOLIC ACID 1MG-TAB,618600,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FOLIC ACID 5MG/ML-INJ,618650,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
FOLTX TAB,618660,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FORANE/15 MINUTES,618674,CDM,250,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,620.16,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
FOLIC ACID 800MG TAB,618675,CDM,250,RC,,,Outpatient,800,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FOSAMAX 5MG-TAB,618681,CDM,250,RC,,,Outpatient,5,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
FOSAMAX 10MG TAB,618685,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
G-PHED PD CAP,618800,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
GEMFIBROZOL 600MG TABLET,618900,CDM,250,RC,,,Outpatient,600,ME,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,257.18,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
GENTAMICIN 60MG/6ML-INJ,619300,CDM,250,RC,J1580,HCPCS,Outpatient,606,ME,35,24.5,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,451.74,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
GEODON 20MG CAP,619375,CDM,250,RC,,,Outpatient,20,ME,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.15,65,,26.52,Percent of Total Billed Charges,65% of Total Billed Charges,38.25,75,,30.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,30.6,60,,24.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,38.76,
GEODON 80MG CAP,619380,CDM,250,RC,,,Outpatient,80,ME,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,29.9,65,,23.92,Percent of Total Billed Charges,65% of Total Billed Charges,34.5,75,,27.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.2,34.96,
GENTAMYCIN 100MG/100ML IV,619425,CDM,250,RC,Y7509,HCPCS,Outpatient,100,ME,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.5,35.72,
GENTAMICIN 3.5 GRAMS-EYE,619500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,118,82.6,,,,,,Other,Not Seperately Reimbusable,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59,89.68,
GENTAMICIN 15 GRAMS-EYE,619525,CDM,250,RC,Y7506,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,661.5,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
GENTAK OPTHALMIC SOL. 0.3%-3MG,619718,CDM,250,RC,Y7506,HCPCS,Outpatient,33,ME,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,992.86,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
GERIVITE LIQUID,619935,CDM,250,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,992.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
GEVRABON 5/10ML LIQ,619950,CDM,250,RC,Y7506,HCPCS,Outpatient,510,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
GLUCOPHAGE 500MG-TAB,620018,CDM,250,RC,,,Outpatient,500,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
GLUCOPHAGE XR 500MG-TAB,620019,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLUCOPHAGE 850MG-TAB,620020,CDM,250,RC,,,Outpatient,850,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,60.19,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
GLUCOVANCE 5MG/500MG TABLET,620022,CDM,250,RC,,,Outpatient,5500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,51.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GI COCKTAIL-BOTTLE,620025,CDM,250,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
GLIPIZIDE 10MG TAB,620030,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLIPIZIDE 5MG U/D -TAB,620040,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLUCOTROL XL 5MG-TAB,620041,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLUCOTROL XL 2.5MG-TAB,620042,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLUCOTROL XL-ER 2.5MG -TAB,620043,CDM,250,RC,,,Outpatient,25,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
GLUCOTROL XL 10MG-TAB,620045,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLUCOVANCE 2.5MG/500MG TABLET,620048,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLYCERIN SUPP,620050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,60.19,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,95.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
GLYCERINE-PEDIATRIC,620051,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,22.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
GLYNASE 3 MG-TAB,620109,CDM,250,RC,,,Outpatient,3,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HALFLYTELY 2L SOLUTION,620132,CDM,250,RC,Y7506,HCPCS,Outpatient,,,256,179.2,,,,,,Other,Not Seperately Reimbusable,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,194.56,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,128,50,,29.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128,194.56,
GOLYTELY 263 GM,620150,CDM,250,RC,,,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,56.25,75,,45,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,45,60,,36,Percent of Total Billed Charges,60% of Total Billed Charges,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,57,
T.B.C. SPRAY,620200,CDM,250,RC,Y7506,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
GUAIFENESIN 200MG/10ML SYRUP,620250,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GUIATUSS PE SYRUP,620259,CDM,250,RC,J7150,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
GUAIFENESIN DM 100MG/5ML SYRUP,620260,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,338.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,284.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GUIATUSS AC SYRUP,620261,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,287.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GUIATUSS PE 100MG/30MG-LIQ,620262,CDM,250,RC,,,Outpatient,100,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,52.29,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
GUIATUSS 100 MG-LIQ,620263,CDM,250,RC,,,Outpatient,100,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
GUANFACINE 1MG TAB,620265,CDM,250,RC,,,Outpatient,1,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
QUINIDINE SULFATE 300MG-PO,620270,CDM,250,RC,,,Outpatient,300,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
GYNE-LOTRIMIN 200MG SUPPOSITOR,620274,CDM,250,RC,Y7506,HCPCS,Outpatient,200,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
GYN-LOTRIMIN VAG CRM,620275,CDM,250,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
GYN-LOTRIMIN VAG TAB,620277,CDM,250,RC,,,Outpatient,,,71,49.7,,,,,,Other,Not Seperately Reimbusable,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.15,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,53.25,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,42.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.2,53.96,
HALOPERIDOL 0.5MG-TAB,620450,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HALOPERIDOL 1MG -TAB,620500,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HALOPERIDOL 5MG-TAB,620600,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HEMABATE 250MCG INJ,620650,CDM,250,RC,,,Outpatient,,,352,246.4,,,,,,Other,Not Seperately Reimbusable,239.36,68,,191.49,Percent of Total Billed Charges,68% of Total Billed Charges,267.52,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,176,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,228.8,65,,183.04,Percent of Total Billed Charges,65% of Total Billed Charges,264,75,,211.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,211.2,60,,168.96,Percent of Total Billed Charges,60% of Total Billed Charges,71.81,20.4,,57.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,71.81,20.4,,57.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.4,20,,56.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,70.4,267.52,
HEPARIN 1000U INJ,620800,CDM,250,RC,J1644,HCPCS,Outpatient,,,9,6.3,,0.29,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
HEPARIN 10000U INJ,620950,CDM,250,RC,J1644,HCPCS,Outpatient,,,14,9.8,,0.29,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HETASTARCH 6% INJECTION,620970,CDM,250,RC,Y7506,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,210.37,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
HISTEX HC 5ML,620990,CDM,250,RC,,,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HISTEX PD 2MG DROPS-LIQ,620991,CDM,250,RC,,,Outpatient,2,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
CARBINOXAMINE PD 4MG/5ML,620992,CDM,250,RC,,,Outpatient,45,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HISTINEX HC 5ML,620994,CDM,250,RC,,,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GUAIFENESIN 1000MG TAB,621005,CDM,250,RC,,,Outpatient,1000,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
MUCINEX 600MG TAB,621010,CDM,250,RC,,,Outpatient,600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HUMULIN U U-100 SUSPENSION,621020,CDM,250,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
HURRICAINE 20% TOPICAL,621100,CDM,250,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,158.08,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
HYDRALAZINE HCL 50MG TABLET,621110,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDRAMINE ELIXIR 12.5 MG/5CC E,621120,CDM,250,RC,,,Outpatient,1255,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,798.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
HYDROCODONE/APAP 5/325MG TAB,621125,CDM,250,RC,,,Outpatient,5325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCODONE/APAP 7.5/325MG TAB,621126,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCIL INSTANT FIBER 95%-POW,621127,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HYDROCODONE/APAP 10/325MG TAB,621128,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDREA 500MG-CAP,621129,CDM,250,RC,,,Outpatient,500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
HYDROCODONE BIT/GUAIFENES 5MG/,621130,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCODONE BIT&ACET 5/500MG T,621131,CDM,250,RC,,,Outpatient,5500,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
HYDROCODONEBIT/APAP 7.5/750MG-,621132,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCODONE/ACETAMINOPHEN 7.5M,621133,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCODONE/ACETAMINOPHEN 10MG,621134,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,57.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROCORTISONE ENEMA 100MG,621137,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,44.84,
HYDROCORTISONE OINT 0.5%,621138,CDM,250,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HYDROCORTISONE 2.5% CREAM,621139,CDM,250,RC,Y7506,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
HYDROCORTISONE 0.5% CREAM,621140,CDM,250,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,43.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HYDROCORTSN 0.5% 28G OINT,621141,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,81.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
HYDROCORTSN 1% 28G C OINT,621142,CDM,250,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,33.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
HYDROCHLOROTHIAZIDE 25MG TAB,621150,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,32.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROMORPHONE 2MG TAB,621200,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROPHOR 454G OINTMENT,621226,CDM,250,RC,Y7506,HCPCS,Outpatient,,,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,84.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,48.64,
HYDROXYZINE HCL 25MG TABLET,621230,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,84.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYDROXYZINE 50MG TABLET,621232,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
HYPAQUE 50% 20 ML  INJ,621338,CDM,250,RC,,,Outpatient,5020,ML,69,48.3,,,,,,Other,Not Seperately Reimbusable,46.92,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,52.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,34.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.85,65,,35.88,Percent of Total Billed Charges,65% of Total Billed Charges,51.75,75,,41.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,41.4,60,,33.12,Percent of Total Billed Charges,60% of Total Billed Charges,14.08,20.4,,11.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.08,20.4,,11.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.8,20,,11.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.8,52.44,
PURALUBE TEARS EYE,621380,CDM,250,RC,Y7506,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,42.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
HYTINIC TAB,621400,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
HYTRIN 1MG CAPSULE,621402,CDM,250,RC,,,Outpatient,1,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,280,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
HYTRIN 5MG CAP,621405,CDM,250,RC,,,Outpatient,5,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,81.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
HYZAAR 50/12.5  TA B,621427,CDM,250,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,46,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
IBERET-FOLIC-500 TAB,621431,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IBUPROFEN 100MG/5ML SYRUP,621432,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,77.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IBUPROFEN 200MG-TAB,621435,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ILETIN I-NPH 100U/ML INJECTION,621439,CDM,250,RC,J1817,HCPCS,Outpatient,100,ML,20,14,,8.75,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
ILETIN I-REGULAR 100U/ML INJEC,621443,CDM,250,RC,J1815,HCPCS,Outpatient,100,ML,20,14,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
HPV VACCINE,621500,CDM,250,RC,90649,HCPCS,Outpatient,,,225,157.5,,163.24,100,,,fee schedule,100% Aetna Market fee schedule,153,68,,122.4,Percent of Total Billed Charges,68% of Total Billed Charges,171,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,112.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.5,171,
ERYTHROMYCIN 0.5% OINT,621726,CDM,250,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
IMFERON 2ML AMP INJ,621750,CDM,250,RC,J1750,HCPCS,Outpatient,2,ML,50,35,,19.06,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,38,
IMITREX 25MG TABLET,621766,CDM,250,RC,,,Outpatient,25,ME,126,88.2,,,,,,Other,Not Seperately Reimbusable,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,95.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,63,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,81.9,65,,65.52,Percent of Total Billed Charges,65% of Total Billed Charges,94.5,75,,75.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.2,20,,20.16,Percent of Total Billed Charges,20% of Total Billed Charges,75.6,60,,60.48,Percent of Total Billed Charges,60% of Total Billed Charges,25.7,20.4,,20.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.7,20.4,,20.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,25.2,20,,20.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.2,20,,20.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.2,95.76,
IMITREX 50MG TAB,621767,CDM,250,RC,,,Outpatient,50,ME,118,82.6,,,,,,Other,Not Seperately Reimbusable,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,76.7,65,,61.36,Percent of Total Billed Charges,65% of Total Billed Charges,88.5,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,70.8,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,24.07,20.4,,19.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.07,20.4,,19.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.6,89.68,
LOPERAMIDE 2MG-TAB,621800,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,144.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IMOGAM HT 10ML INJ,621820,CDM,250,RC,,,Outpatient,10,ML,451,315.7,,,,,,Other,Not Seperately Reimbusable,306.68,68,,245.34,Percent of Total Billed Charges,68% of Total Billed Charges,342.76,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,225.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,293.15,65,,234.52,Percent of Total Billed Charges,65% of Total Billed Charges,338.25,75,,270.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.2,20,,72.16,Percent of Total Billed Charges,20% of Total Billed Charges,270.6,60,,216.48,Percent of Total Billed Charges,60% of Total Billed Charges,92,20.4,,73.6,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92,20.4,,73.6,Percent of Total Billed Charges,20.4% of Total Billed Charges,90.2,20,,72.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.2,20,,72.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90.2,342.76,
LOPERAMIDE 5ML SOLN,621825,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
IMURAN 50MG-TAB,621826,CDM,250,RC,,,Outpatient,50,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,141.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PROPRANOLOL HCI 10MG-TAB,621950,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROPRANOLOL HCI 20MG TAB,622000,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,432.29,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROPRANOLOL 80MG TAB,622010,CDM,250,RC,,,Outpatient,80,ME,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
INDERAL LA 80MG-TAB,622110,CDM,250,RC,,,Outpatient,80,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
INDIGO CARMINE 0.8% INJECTION,622151,CDM,250,RC,,,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,65,,30.16,Percent of Total Billed Charges,65% of Total Billed Charges,43.5,75,,34.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,34.8,60,,27.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,44.08,
INDOMETHACIN 25MG -CAP,622200,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
INFASURF 105MG,622240,CDM,250,RC,,,Outpatient,105,ME,2086,1460.2,,,,,,Other,Not Seperately Reimbusable,1418.48,68,,1134.78,Percent of Total Billed Charges,68% of Total Billed Charges,1585.36,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,1043,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,1355.9,65,,1084.72,Percent of Total Billed Charges,65% of Total Billed Charges,1564.5,75,,1251.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.2,20,,333.76,Percent of Total Billed Charges,20% of Total Billed Charges,1251.6,60,,1001.28,Percent of Total Billed Charges,60% of Total Billed Charges,425.54,20.4,,340.43,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,425.54,20.4,,340.43,Percent of Total Billed Charges,20.4% of Total Billed Charges,417.2,20,,333.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,417.2,20,,333.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,417.2,1585.36,
IMDUR 30MG-TAB,622254,CDM,250,RC,,,Outpatient,30,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
INSPRA 25MG TAB,622330,CDM,250,RC,,,Outpatient,25,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
INSTA GLUCOSE TRI-PAK 3X31GM,622343,CDM,250,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,73.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
INVEGA 3MG TAB,622357,CDM,250,RC,,,Outpatient,3,ME,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
INVEGA 6MG TAB,622359,CDM,250,RC,,,Outpatient,6,ME,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,24,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
INVEGA 9MG TAB,622361,CDM,250,RC,,,Outpatient,9,ME,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
INTAL INHALER,622376,CDM,250,RC,Y7506,HCPCS,Outpatient,,,495,346.5,,,,,,Other,Not Seperately Reimbusable,336.6,68,,269.28,Percent of Total Billed Charges,68% of Total Billed Charges,376.2,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,247.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.5,376.2,
IONAMIN 30MG TABLET,622380,CDM,250,RC,,,Outpatient,30,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
IOPHEN DM-NR LIQUID,622405,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IOPIDINE 0.5% DROPS-EYE,622410,CDM,250,RC,Y7506,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
IPECAC 30ML SYRUP,622450,CDM,250,RC,,,Outpatient,30,ML,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ISMO 20MG-TAB,622461,CDM,250,RC,,,Outpatient,20,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,280.9,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
ISONIAZID 300MG TAB,622650,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,417.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ISOPTIN 40MG TAB,622710,CDM,250,RC,,,Outpatient,40,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,123.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ISOPTO CARBACHOL OPTHAL 3% SOL,622715,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
TEARISOL 0.5%-EYE,622725,CDM,250,RC,Y7506,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
ISOSORBIDE DINITRATE 10MG-TAB,622850,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ISOSRBIDE DINITRATE 20MG-TAB,622900,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,159.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ISOSORBIDE MONONITRATE 30MG TA,622925,CDM,250,RC,,,Outpatient,30,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1214.18,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ISOSORBIDE MONONITRATE 60MG TA,622927,CDM,250,RC,,,Outpatient,60,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ISUPREL 1MG INJECTION,623045,CDM,250,RC,,,Outpatient,1,ME,118,82.6,,,,,,Other,Not Seperately Reimbusable,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,76.7,65,,61.36,Percent of Total Billed Charges,65% of Total Billed Charges,88.5,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,70.8,60,,56.64,Percent of Total Billed Charges,60% of Total Billed Charges,24.07,20.4,,19.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.07,20.4,,19.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.6,20,,18.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.6,89.68,
ISUPREL 0.2MG INJECTION,623046,CDM,250,RC,,,Outpatient,2,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
"ISUPREL 1:50,000 SYR INJ",623125,CDM,250,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
K-DUR 20 MEQ -TAB,623194,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
JANUVIA 50MG TAB,623225,CDM,250,RC,,,Outpatient,50,ME,77,53.9,,,,,,Other,Not Seperately Reimbusable,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,58.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,38.5,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.05,65,,40.04,Percent of Total Billed Charges,65% of Total Billed Charges,57.75,75,,46.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,20,,12.32,Percent of Total Billed Charges,20% of Total Billed Charges,46.2,60,,36.96,Percent of Total Billed Charges,60% of Total Billed Charges,15.71,20.4,,12.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.71,20.4,,12.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.4,20,,12.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.4,20,,12.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.4,58.52,
JANUVIA 100MG TAB,623250,CDM,250,RC,,,Outpatient,100,ME,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.05,65,,19.24,Percent of Total Billed Charges,65% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.2,60,,17.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.4,28.12,
XARELTO 10MG TAB,623300,CDM,250,RC,,,Outpatient,10,ME,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,56.25,75,,45,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,45,60,,36,Percent of Total Billed Charges,60% of Total Billed Charges,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,57,
KADIAN 50MG CAP,623350,CDM,250,RC,,,Outpatient,50,ME,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
KALETRA 100/25MG TAB,623360,CDM,250,RC,,,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,86.94,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
XALATAN 0.005% EYE,623378,CDM,250,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
KAO-TIN 750MG/15ML,623400,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
K-PEK 750MG/15ML,623550,CDM,250,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,65.66,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,52.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
KAYEXALATE 15G -PO,623611,CDM,250,RC,,,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,124.03,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.25,75,,33,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,33,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11,41.8,
CEPHALEXIN 250MG-CAP,623648,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CEPHALEXIN 500MG-CAP,623700,CDM,250,RC,,,Outpatient,500,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,49.86,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
CEPHALEXIN 250MG/5ML 100ML-SUS,623900,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CEPHALEXIN 250MG/5ML 200ML-SUS,623925,CDM,250,RC,,,Outpatient,250,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,147.14,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
KENALOG .025% 15G CREAM,624100,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
KENALOG .025% 15G OINT,624150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
KEPPRA 500MG IV,624185,CDM,250,RC,Y7507,HCPCS,Outpatient,500,ME,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,2.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
KEPRA 500MG TAB,624190,CDM,250,RC,,,Outpatient,500,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,68.7,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,360.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
TRIAMCINOLONE 0.1% OINT,624200,CDM,250,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
TRIAMCINO DENTAL PASTE 5GM,624225,CDM,250,RC,Y7506,HCPCS,Outpatient,,,95,66.5,,,,,,Other,Not Seperately Reimbusable,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,72.2,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,47.5,50,,120.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.5,72.2,
TRIAMCINOLONE 0.025% CREAM,624240,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TRIAMCINOLONE 0.1% CREAM,624250,CDM,250,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
TRIAMCINOLONE 0.5% CREAM,624260,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,425.6,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
TRIAMCINOLONE 0.5% OINT,624275,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,123.42,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
KETOLOLAC 0.5% OPH SOLUTION,624550,CDM,250,RC,,,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,78,65,,62.4,Percent of Total Billed Charges,65% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,72,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,91.2,
TRICOR 48MG TAB,624590,CDM,250,RC,,,Outpatient,48,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
KETAMINE 50MG/ML INJ,624595,CDM,250,RC,Y7506,HCPCS,Outpatient,50,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
KETAMINE 500MG/5ML 1ML INJECTI,624596,CDM,250,RC,,,Outpatient,,,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
TRICOR 145MG TAB,624600,CDM,250,RC,,,Outpatient,145,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
TRIFLURIDINE OPTH DROPS,624625,CDM,250,RC,Y7506,HCPCS,Outpatient,,,405,283.5,,,,,,Other,Not Seperately Reimbusable,275.4,68,,220.32,Percent of Total Billed Charges,68% of Total Billed Charges,307.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,202.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.5,307.8,
KLONOPIN 0.5MG TABLET,624727,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
K-DUR 10MEQ TABLET,624780,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1099.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
KLOR-CON M20 20MEQ TABLET,624785,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LYRICA 50MG CAP,624900,CDM,250,RC,,,Outpatient,50,ME,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.55,65,,24.44,Percent of Total Billed Charges,65% of Total Billed Charges,35.25,75,,28.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,28.2,60,,22.56,Percent of Total Billed Charges,60% of Total Billed Charges,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.59,20.4,,7.67,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.4,20,,7.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.4,35.72,
LAC-HYDRIN LOTION 12%,624990,CDM,250,RC,Y7506,HCPCS,Outpatient,,,310,217,,,,,,Other,Not Seperately Reimbusable,210.8,68,,168.64,Percent of Total Billed Charges,68% of Total Billed Charges,235.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,155,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155,235.6,
LACRI-LUBE 3.5G OPTH EYE,625000,CDM,250,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
LACRI-LUBE OPTH/PT-EYE,625050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,158.08,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,52.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PERPHENAZINE 2MG TAB,625075,CDM,250,RC,,,Outpatient,2,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,215.23,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
LACTAID ULTRA,625090,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,46.21,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
LACTINEX 1G GRANULES,625100,CDM,250,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
LACTULOSE 10MG/15ML SUSPENSION,625103,CDM,250,RC,,,Outpatient,1015,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LACTULOSE 20GM/30ML SYRUP,625104,CDM,250,RC,,,Outpatient,2030,ML,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
DUPHALAC 10GM -LIQ,625105,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
LAMICTAL 25MG TAB,625108,CDM,250,RC,,,Outpatient,25,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
LAMICTAL 100MG TABLET,625109,CDM,250,RC,,,Outpatient,100,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
LAMICTAL 200MG TABLET,625110,CDM,250,RC,,,Outpatient,200,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
LAMISIL CREAM 1%,625113,CDM,250,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
LAMICTAL 250MG TAB,625115,CDM,250,RC,,,Outpatient,250,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
LAMISIL 250MG-TAB,625116,CDM,250,RC,,,Outpatient,250,ME,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.6,65,,33.28,Percent of Total Billed Charges,65% of Total Billed Charges,48,75,,38.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,38.4,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.8,48.64,
LANOXICAP 0.1MG U/O  CAP,625125,CDM,250,RC,,,Outpatient,1,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
LANOXICAPS .05MG CAPSULE,625127,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,57.76,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,18.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
LANOXIN 0.125MG TAB,625150,CDM,250,RC,,,Outpatient,125,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LANOXIN  .25MG TABLET,625200,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LANOXIN ELIXIR 60ML ORAL,625250,CDM,250,RC,Y7506,HCPCS,Outpatient,60,ML,164,114.8,,,,,,Other,Not Seperately Reimbusable,111.52,68,,89.22,Percent of Total Billed Charges,68% of Total Billed Charges,124.64,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,82,50,,172.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,124.64,
LANOXIN PEDIATRIC LIQ,625350,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6415.01,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
LANSINOH,625352,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
KETEK 400MG CAP,625498,CDM,250,RC,,,Outpatient,400,ME,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,292,Percent of Total Billed Charges,50% of Total Billed Charges,24.05,65,,19.24,Percent of Total Billed Charges,65% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.2,60,,17.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.4,28.12,
AMOXICILLIN 250MG/5ML-SUSP,625705,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FUROSEMIDE 20MG -TAB,625750,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FUROSEMIDE 40MG-TAB,625800,CDM,250,RC,,,Outpatient,40,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LASIX ELIXIR 60ML ORAL,626050,CDM,250,RC,,,Outpatient,60,ML,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,75,,35.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,35.4,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.8,44.84,
LATUDA 40MG TAB,626075,CDM,250,RC,,,Outpatient,40,ME,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,104,65,,83.2,Percent of Total Billed Charges,65% of Total Billed Charges,120,75,,96,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,96,60,,76.8,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32,121.6,
LATUDA 60MG TAB,626077,CDM,250,RC,,,Outpatient,60,ME,196,137.2,,,,,,Other,Not Seperately Reimbusable,133.28,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,148.96,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,98,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.4,65,,101.92,Percent of Total Billed Charges,65% of Total Billed Charges,147,75,,117.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.2,20,,31.36,Percent of Total Billed Charges,20% of Total Billed Charges,117.6,60,,94.08,Percent of Total Billed Charges,60% of Total Billed Charges,39.98,20.4,,31.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.98,20.4,,31.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,39.2,20,,31.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.2,20,,31.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,39.2,148.96,
LATUDA 80MG TAB,626080,CDM,250,RC,,,Outpatient,80,ME,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,104,65,,83.2,Percent of Total Billed Charges,65% of Total Billed Charges,120,75,,96,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,96,60,,76.8,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32,121.6,
LESCOL 20 MG -CAP,626133,CDM,250,RC,,,Outpatient,20,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
LEUKERAN 2MG TAB,626150,CDM,250,RC,,,Outpatient,2,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
LEVALL 5/5/20/100MG LIQUID,626155,CDM,250,RC,,,Outpatient,100,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,187.26,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
LEVALL 20MG/15MG/100MG LIQUID,626156,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LEVALL LIQUID 20/5/20/100MG LI,626157,CDM,250,RC,,,Outpatient,100,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
LEVAQUIN 500MG TABLET,626160,CDM,250,RC,,,Outpatient,500,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,104,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
LEVAQUIN 750MG TAB,626162,CDM,250,RC,,,Outpatient,750,ME,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,241.98,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.5,65,,15.6,Percent of Total Billed Charges,65% of Total Billed Charges,22.5,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,22.8,
LEVAQUIN INJ 500MG/20ML INJ,626163,CDM,250,RC,J1956,HCPCS,Outpatient,,,211,147.7,,1,100,,,fee schedule,100% Aetna Market fee schedule,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,105.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,160.36,
LEVAQUIN 250MG TAB,626165,CDM,250,RC,,,Outpatient,250,ME,60,42,,,,,,Other,Not Seperately Reimbusable,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,45.6,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,30,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,39,65,,31.2,Percent of Total Billed Charges,65% of Total Billed Charges,45,75,,36,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,20,,9.6,Percent of Total Billed Charges,20% of Total Billed Charges,36,60,,28.8,Percent of Total Billed Charges,60% of Total Billed Charges,12.24,20.4,,9.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.24,20.4,,9.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,12,20,,9.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,20,,9.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12,45.6,
LEVETIRACETAM 500MG PM-INJ,626175,CDM,250,RC,,,Outpatient,500,ME,99,69.3,,,,,,Other,Not Seperately Reimbusable,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,75.24,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,64.35,65,,51.48,Percent of Total Billed Charges,65% of Total Billed Charges,74.25,75,,59.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,59.4,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,20.2,20.4,,16.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.2,20.4,,16.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.8,75.24,
LEVETIRACETAM 1GM PM-INJ,626190,CDM,250,RC,,,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,161.84,68,,129.47,Percent of Total Billed Charges,68% of Total Billed Charges,180.88,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,119,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,154.7,65,,123.76,Percent of Total Billed Charges,65% of Total Billed Charges,178.5,75,,142.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.6,20,,38.08,Percent of Total Billed Charges,20% of Total Billed Charges,142.8,60,,114.24,Percent of Total Billed Charges,60% of Total Billed Charges,48.55,20.4,,38.84,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.55,20.4,,38.84,Percent of Total Billed Charges,20.4% of Total Billed Charges,47.6,20,,38.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.6,20,,38.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.6,180.88,
LEVETIRACETAM 100MG/ML ORAL SU,626191,CDM,250,RC,,,Outpatient,100,ME,89,62.3,,,,,,Other,Not Seperately Reimbusable,60.52,68,,48.42,Percent of Total Billed Charges,68% of Total Billed Charges,67.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,44.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,57.85,65,,46.28,Percent of Total Billed Charges,65% of Total Billed Charges,66.75,75,,53.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.8,20,,14.24,Percent of Total Billed Charges,20% of Total Billed Charges,53.4,60,,42.72,Percent of Total Billed Charges,60% of Total Billed Charges,18.16,20.4,,14.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.16,20.4,,14.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,17.8,20,,14.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.8,20,,14.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.8,67.64,
TRANEXAMIC ACID 1000MG INJ SDV,626192,CDM,250,RC,,,Outpatient,1000,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
LEVOPHED 4MG/4ML  INJ,626200,CDM,250,RC,Y7506,HCPCS,Outpatient,44,ME,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,2.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
LEVOTHROID 150 MCG-TAB,626202,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LEVOTHYROXINE 200MCG TABLET,626204,CDM,250,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36.48,
LEVOTHYROXINE 200MG INJ,626205,CDM,250,RC,,,Outpatient,200,ME,104,72.8,,,,,,Other,Not Seperately Reimbusable,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,79.04,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.6,65,,54.08,Percent of Total Billed Charges,65% of Total Billed Charges,78,75,,62.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,62.4,60,,49.92,Percent of Total Billed Charges,60% of Total Billed Charges,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.8,79.04,
LEVSIN SL 0.125MG TAB,626215,CDM,250,RC,,,Outpatient,125,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
LEXAPRO 20MG TAB,626220,CDM,250,RC,,,Outpatient,20,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
CHLORDIAZEPOXIDE 5MG-2.5MG CAP,626250,CDM,250,RC,,,Outpatient,525,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,98.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHLORDIAZEPOXIDE 10MG CAP,626350,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,79.65,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHLORDIAZEPOXIDE 25MG-CAP,626400,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LIBRIUM 100MG AMP INJ,626450,CDM,250,RC,J1990,HCPCS,Outpatient,100,ME,150,105,,21.31,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
LIDEX 0.05% 60G OINT,626490,CDM,250,RC,Y7506,HCPCS,Outpatient,,,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,249.28,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,39.52,
FLUOCINIDE 15GM OINT,626495,CDM,250,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
LIDJEL,626496,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
LIDOCAINE 0.5% 50ML  INJ,626498,CDM,250,RC,,,Outpatient,50,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,309.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FLUMIST QUAD 0.2ML INTRANASAL,626499,CDM,250,RC,,,Outpatient,2,ML,125,87.5,,,,,,Other,Not Seperately Reimbusable,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,81.25,65,,65,Percent of Total Billed Charges,65% of Total Billed Charges,93.75,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,75,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,95,
LIDOCAINE GEL 2% URO TOPICAL,626500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,30,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
LIDOCAINE HCL 1% 50MG/5ML INJ,626550,CDM,250,RC,,,Outpatient,1505,ME,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
LIDOCAINE 2% GEL,626755,CDM,250,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
LIDODERM 5% PATCH,626760,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,454,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
LINCOCIN 600MG/2ML S INJ,626950,CDM,250,RC,J2010,HCPCS,Outpatient,6002,ME,27,18.9,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,120.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
LINDANE 1% SOLUTION,627004,CDM,250,RC,Y7506,HCPCS,Outpatient,,,660,462,,,,,,Other,Not Seperately Reimbusable,448.8,68,,359.04,Percent of Total Billed Charges,68% of Total Billed Charges,501.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,330,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,501.6,
LINDANE 1% 60ML LOTION,627006,CDM,250,RC,Y7506,HCPCS,Outpatient,160,ML,602,421.4,,,,,,Other,Not Seperately Reimbusable,409.36,68,,327.49,Percent of Total Billed Charges,68% of Total Billed Charges,457.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,301,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301,457.52,
LIOTHYRONINE 5 MCG TAB,627010,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
LIPITOR 10MG -TAB,627012,CDM,250,RC,,,Outpatient,10,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
LIPITOR 20MG-TAB,627015,CDM,250,RC,,,Outpatient,20,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,264,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
LIPITOR 80MG TAB,627020,CDM,250,RC,,,Outpatient,80,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
LITHANE 300MG TAB,627050,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LODINE 200 CAP,627075,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
LODINE 300MG  CAP,627077,CDM,250,RC,,,Outpatient,300,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
DIPHENOXYLATE HCI ATROP IN TAB,627100,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIPHENOXYLATE 2.5MG -TAB,627150,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1671.39,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LOPID 600MG-TAB,627177,CDM,250,RC,,,Outpatient,600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,49.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIPIVEFRIN 0.1% OPTH,627180,CDM,250,RC,,,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,79.65,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,114,
METOPROLOL TARTRATE 50MG-TAB,627200,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LO/OVRAL-28 TABLETS,627201,CDM,250,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,27.56,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,31.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
LORATADINE 10MG TAB,627250,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LORAZEPAM 1MG TABLET,627270,CDM,250,RC,,,Outpatient,1,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
LORAZEPAM 2MG TABLET,627272,CDM,250,RC,,,Outpatient,2,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
LORCET 10MG/65MG  TAB,627295,CDM,250,RC,,,Outpatient,1065,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
LORCET PLUS  7.5MG/650MG TAB,627298,CDM,250,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
LOTENSIN 10MG TAB,627375,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LOTENSIN HCT 20/12.5MG TABLET,627377,CDM,250,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
LOTENSIN 20MG TAB,627378,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LOTREL 2.5MG/10MG-TAB,627380,CDM,250,RC,,,Outpatient,2510,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
LOTREL 5/10 CAP,627382,CDM,250,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,155.65,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
LOTREL 5/20 CAP,627385,CDM,250,RC,,,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
LOTREL 10/20MG CAP,627390,CDM,250,RC,,,Outpatient,1020,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
LOVAZA 1GM CAP,627400,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
LOTRIMIN CR 30GM CREAM,627403,CDM,250,RC,Y7506,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,49.4,
LOTRISONE CREAM 15G,627414,CDM,250,RC,Y7506,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.5,104.12,
LOZOL 1.25MG-TAB,627419,CDM,250,RC,,,Outpatient,125,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
LOZOL 2.5MG  TAB,627420,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
LUDIOMIL 75MG TABLET,627450,CDM,250,RC,,,Outpatient,75,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,443.84,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
LUGOLS SOLN PER PT,627550,CDM,250,RC,Y7506,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
LUMIGAN 0.01% EYEDROP,627570,CDM,250,RC,Y7506,HCPCS,Outpatient,,,330,231,,,,,,Other,Not Seperately Reimbusable,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,99.71,Percent of Total Billed Charges,76% of Total Billed Charges,165,50,,74.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,250.8,
HALEY'S MO,627600,CDM,250,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,43.17,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,46.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ALAMAG 12OZ,627850,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ALBENZA 200MG TAB,627900,CDM,250,RC,,,Outpatient,200,ME,878,614.6,,,,,,Other,Not Seperately Reimbusable,597.04,68,,477.63,Percent of Total Billed Charges,68% of Total Billed Charges,667.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,439,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,570.7,65,,456.56,Percent of Total Billed Charges,65% of Total Billed Charges,658.5,75,,526.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.6,20,,140.48,Percent of Total Billed Charges,20% of Total Billed Charges,526.8,60,,421.44,Percent of Total Billed Charges,60% of Total Billed Charges,179.11,20.4,,143.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,179.11,20.4,,143.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,175.6,20,,140.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.6,20,,140.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,175.6,667.28,
NITROFURANTOIN 50MG CAP,628000,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,63.23,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MACROBID 100MG CAP,628020,CDM,250,RC,,,Outpatient,100,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
LIPRAM CAP,628025,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MSIR 15MG TAB,628030,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,70.53,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MAALOX SYRUP,628040,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MAALOX PLUS,628041,CDM,250,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,239.55,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
MAALOX 5OZ BOTTLE,628042,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
MACRODANTN 100MG CAP,628050,CDM,250,RC,,,Outpatient,100,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,158.08,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
MAG-OX 400MG TAB,628066,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MARCAINE 0.5% INJ,628325,CDM,250,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
MARCAINE 0.25% INJ,628331,CDM,250,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,382,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
MATERNA 1-60 TAB,628375,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,676.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
MARINOL 2.5MG CAP,628400,CDM,250,RC,,,Outpatient,25,ME,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
MAXAIR AUTO INHALER 0.2MG,628403,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,77,53.9,,,,,,Other,Not Seperately Reimbusable,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,58.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,38.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,58.52,
MAXAIR 0.2MG  INHALER,628404,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,290,203,,,,,,Other,Not Seperately Reimbusable,197.2,68,,157.76,Percent of Total Billed Charges,68% of Total Billed Charges,220.4,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,145,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145,220.4,
MAXIPIME 2GM-INJ,628407,CDM,250,RC,Y7506,HCPCS,Outpatient,,,219,153.3,,,,,,Other,Not Seperately Reimbusable,148.92,68,,119.14,Percent of Total Billed Charges,68% of Total Billed Charges,166.44,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,109.5,50,,2.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.5,166.44,
MAXITROL-EYE,628409,CDM,250,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
MAXITROL 3.5G OPTH O EYE,628410,CDM,250,RC,Y7506,HCPCS,Outpatient,,,214,149.8,,,,,,Other,Not Seperately Reimbusable,145.52,68,,116.42,Percent of Total Billed Charges,68% of Total Billed Charges,162.64,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107,162.64,
MAXZIDE 37.5MG/25MG -TAB,628425,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MAZICON 5ML-INJ,628437,CDM,250,RC,,,Outpatient,5,ML,71,49.7,,,,,,Other,Not Seperately Reimbusable,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.15,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,53.25,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,42.6,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.48,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.2,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.2,53.96,
MEBENDAZOLE 100MG TAB,628650,CDM,250,RC,,,Outpatient,100,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,47.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
MEGESTROL ACETATE 40MG,628762,CDM,250,RC,,,Outpatient,40,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,137.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MEGESTROL ACETATE 400MG/10ML S,628763,CDM,250,RC,,,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,121.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
MELATONIN 3MG-TAB,628772,CDM,250,RC,,,Outpatient,3,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
THIORIDAZINE 10MG TAB,628800,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
THIORIDAZINE 25MG TAB,628900,CDM,250,RC,,,Outpatient,25,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,690.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
THIORIDAZINE 50MG TAB,628950,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MELLARIL ORAL SOLUTION 100MG/M,629100,CDM,250,RC,,,Outpatient,100,ME,249,174.3,,,,,,Other,Not Seperately Reimbusable,169.32,68,,135.46,Percent of Total Billed Charges,68% of Total Billed Charges,189.24,76,,183.01,Percent of Total Billed Charges,76% of Total Billed Charges,124.5,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,161.85,65,,129.48,Percent of Total Billed Charges,65% of Total Billed Charges,186.75,75,,149.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.8,20,,39.84,Percent of Total Billed Charges,20% of Total Billed Charges,149.4,60,,119.52,Percent of Total Billed Charges,60% of Total Billed Charges,50.8,20.4,,40.64,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.8,20.4,,40.64,Percent of Total Billed Charges,20.4% of Total Billed Charges,49.8,20,,39.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.8,20,,39.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.8,189.24,
MEPERIDINE HCL/PROMETHAZI 50MG,629190,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,401.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,364.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MEPHYTON 5MG TAB,629200,CDM,250,RC,,,Outpatient,5,ME,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,65,,30.16,Percent of Total Billed Charges,65% of Total Billed Charges,43.5,75,,34.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,34.8,60,,27.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,44.08,
METAMUCIL PACKETS,629250,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,512.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
METFORMIN 500MG TABLET,629300,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,664.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METFORMIN 850MG TAB,629350,CDM,250,RC,,,Outpatient,850,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
METFORMIN 1000MG TAB,629375,CDM,250,RC,,,Outpatient,1000,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,75.39,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHADONE 10MG TAB,629390,CDM,250,RC,,,Outpatient,10,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
METHIMAZOLE,629458,CDM,250,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
MELOXICAM 7.5MG TAB,629500,CDM,250,RC,,,Outpatient,75,ME,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,10.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
METHOTREXATE 50MG INJ,629575,CDM,250,RC,J9260,HCPCS,Outpatient,50,ME,93,65.1,,3.34,100,,,fee schedule,100% Aetna Market fee schedule,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,70.68,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,46.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.5,70.68,
METHLDOPA 250MG TABLET,629578,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHYLENE BLUE 1% INJECTION,629580,CDM,250,RC,,,Outpatient,,,450,315,,,,,,Other,Not Seperately Reimbusable,306,68,,244.8,Percent of Total Billed Charges,68% of Total Billed Charges,342,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,225,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,292.5,65,,234,Percent of Total Billed Charges,65% of Total Billed Charges,337.5,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,270,60,,216,Percent of Total Billed Charges,60% of Total Billed Charges,91.8,20.4,,73.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,91.8,20.4,,73.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,90,342,
METHYLPHENIDATE 5MG-TAB,629593,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHYLPHENIDATE 10MG TABLET,629594,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
METHYLPHENIDATE 20MG TABLET,629595,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METOCLOPRAMIDE 5MG SYRUP,629645,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METROGEL 0.75% VAGINAL,629651,CDM,250,RC,Y7506,HCPCS,Outpatient,,,350,245,,,,,,Other,Not Seperately Reimbusable,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,60.19,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,266,
METROGEL 1% GEL TOPICAL,629652,CDM,250,RC,Y7506,HCPCS,Outpatient,,,275,192.5,,,,,,Other,Not Seperately Reimbusable,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,137.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.5,209,
MEVACOR 20MG  TAB,629653,CDM,250,RC,,,Outpatient,20,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
MIACALCIN 200IU  NASAL,629656,CDM,250,RC,Y7506,HCPCS,Outpatient,,,416,291.2,,,,,,Other,Not Seperately Reimbusable,282.88,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,316.16,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,208,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208,316.16,
MICRO K EXT ENTAB 8MEQ(600MG),629657,CDM,250,RC,,,Outpatient,8600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
POTASSIUM CHLORIDE E.R 10MEQ C,629658,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLYBURIDE TABLET 5MG,629662,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MIDAZOLAM 2MG/2ML INJECTION,629670,CDM,250,RC,Y7506,HCPCS,Outpatient,22,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
MIDODRINE 5MG TAB,629673,CDM,250,RC,,,Outpatient,5,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
MIDRIN CAP 65/100/325MG CAP,629675,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
MIGRATINE CAP,629685,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
MILK OF MAG 30CC,629700,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MINERAL OIL 16OZ,629750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,113.09,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
MINERAL OIL 10ML VIAL,629755,CDM,250,RC,Y7506,HCPCS,Outpatient,10,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,114.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PRAZOSIN HCL 1MG CAP,629800,CDM,250,RC,,,Outpatient,1,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
PRAZOSIN 5MG CAP,629850,CDM,250,RC,,,Outpatient,5,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
MINITRAN 0.4MG/HR-PATCH,629861,CDM,250,RC,Y7506,HCPCS,Outpatient,4,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
MINOCYCLINE HCI 50MG TABLET,629950,CDM,250,RC,,,Outpatient,50,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
MINOXIDIL 10MG-TAB,629960,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
MIRALAX 17GM PACKET,629970,CDM,250,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
MIRALAX 255GM-LIQ,629977,CDM,250,RC,,,Outpatient,,,131,91.7,,,,,,Other,Not Seperately Reimbusable,89.08,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,99.56,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,65.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.15,65,,68.12,Percent of Total Billed Charges,65% of Total Billed Charges,98.25,75,,78.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.2,20,,20.96,Percent of Total Billed Charges,20% of Total Billed Charges,78.6,60,,62.88,Percent of Total Billed Charges,60% of Total Billed Charges,26.72,20.4,,21.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.72,20.4,,21.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.2,20,,20.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.2,20,,20.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.2,99.56,
MIRAPEX 0.25MG TAB,629980,CDM,250,RC,,,Outpatient,25,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
MIVACRON 2MG/ML INJ,629983,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,112,78.4,,,,,,Other,Not Seperately Reimbusable,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
MIRTAZAPINE 30MG TAB,629990,CDM,250,RC,,,Outpatient,30,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
MODURETIC 5/50 TAB,630089,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MICARDIS 20MG TAB,630100,CDM,250,RC,,,Outpatient,20,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
MICONAZOLE NITRATE VAG CREAM 4,630150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
MONISTAT 7 VAG TAB,630154,CDM,250,RC,Y7506,HCPCS,Outpatient,,,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
MONOPRIL 10MG TAB,630170,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
MORPHINE SULFATE 8MG/ML-INJ,630208,CDM,250,RC,,,Outpatient,8,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
IBUPROFEN 400MG TAB,630300,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MOTRIN SUSP/BOTTLE,630351,CDM,250,RC,,,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
MS CONTIN 15MG TAB,630352,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,83.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MULTAQ 400MG TAB,630355,CDM,250,RC,,,Outpatient,400,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
MUCOFEN 800MG TAB,630364,CDM,250,RC,,,Outpatient,800,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
MUCO-FEN 800MG/60MG-TAB,630365,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
MUMPS SKIN TEST 40 CFU/ML INJ,630368,CDM,250,RC,Y7506,HCPCS,Outpatient,40,ML,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
IBUPROFEN 800MG-TAB,630370,CDM,250,RC,,,Outpatient,800,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IC-GREEN 25MG,630380,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ME,565,395.5,,,,,,Other,Not Seperately Reimbusable,384.2,68,,307.36,Percent of Total Billed Charges,68% of Total Billed Charges,429.4,76,,587.33,Percent of Total Billed Charges,76% of Total Billed Charges,282.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.5,429.4,
MVI-12 2 X 5 CC  INJ,630403,CDM,250,RC,,,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
MYAMBUTOL 400MG TAB,630450,CDM,250,RC,,,Outpatient,400,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
MYCOLOG 15G CREAM,630600,CDM,250,RC,Y7506,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,208.54,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,44.08,
NYSTATION/TRIAMCINOL OINTMENT,630650,CDM,250,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,184.22,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NYSTATIN/TRIAMCINOLONE 1000000,630652,CDM,250,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,190.3,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NYSTATIN 100MG TAB-VAG,630725,CDM,250,RC,,,Outpatient,100,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
NYSTATIN 60 CC  SUSP,630750,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MYCOSTATIN CR 15GM CREAM,630799,CDM,250,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
MYFORTIC 180MG TAB,630895,CDM,250,RC,,,Outpatient,180,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
MYFORTIC 360MG TAB,630900,CDM,250,RC,,,Outpatient,360,ME,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,137.41,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,65,,22.36,Percent of Total Billed Charges,65% of Total Billed Charges,32.25,75,,25.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,32.68,
MYDFRIN 2.5% EYE,630913,CDM,250,RC,Y7506,HCPCS,Outpatient,,,123,86.1,,,,,,Other,Not Seperately Reimbusable,83.64,68,,66.91,Percent of Total Billed Charges,68% of Total Billed Charges,93.48,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,61.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,93.48,
TROPICAMIDE -EYE,630920,CDM,250,RC,Y7506,HCPCS,Outpatient,,,102,71.4,,,,,,Other,Not Seperately Reimbusable,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
MYLANTA 15ML SUSP,630950,CDM,250,RC,,,Outpatient,15,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
MYLANTA 30ML SUSP,631000,CDM,250,RC,,,Outpatient,30,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,223.14,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
MI-ACID 12 OZ. LIQ,631050,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MYLANTA CHEW TAB,631054,CDM,250,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,218.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
SIMETHICONE 80MG  TAB,631300,CDM,250,RC,,,Outpatient,80,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SIMETHICONE DROPS 30ML,631350,CDM,250,RC,,,Outpatient,30,ML,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
MYRBETRIQ 25MG,631400,CDM,250,RC,,,Outpatient,25,ME,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,39,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,31.2,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,39.52,
MYSOLINE 50MG TAB,631450,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NAFCILLIN SODIUM 1GM INJ,631639,CDM,250,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NAFCILLIN SODIUM 2GM INJ,631640,CDM,250,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
NALBUPHINE HCL 20MG-INJ,631647,CDM,250,RC,J2300,HCPCS,Outpatient,20,ME,49,34.3,,3.09,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
NALOXEGOL 12.5MG TAB,631735,CDM,250,RC,,,Outpatient,125,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
NALDECON 5ML PED SYR,631750,CDM,250,RC,,,Outpatient,5,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
NALOXONE 0.4MG/ML 10ML INJ,631760,CDM,250,RC,Y7506,HCPCS,Outpatient,410,ME,196,137.2,,,,,,Other,Not Seperately Reimbusable,133.28,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,148.96,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,98,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98,148.96,
NALDECON 30ML PED DR,631800,CDM,250,RC,,,Outpatient,30,ML,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
NALOXONE MDV 4MG/ML INJ,631850,CDM,250,RC,J2310,HCPCS,Outpatient,4,ME,29,20.3,,8.02,100,,,fee schedule,100% Aetna Market fee schedule,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NAMENDA 5MG TAB,631860,CDM,250,RC,,,Outpatient,5,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
NALTREXONE 50MG TAB,631865,CDM,250,RC,,,Outpatient,50,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
NAPROXEN EC 500MG,631925,CDM,250,RC,,,Outpatient,500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
NAPROXEN 250MG TAB,631950,CDM,250,RC,,,Outpatient,250,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,73.57,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
NAPROSYN 500 MG TAB,631951,CDM,250,RC,,,Outpatient,500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
NALMEFENE 2 MG INJ SDV,631998,CDM,250,RC,,,Outpatient,2,ME,156,109.2,,,,,,Other,Not Seperately Reimbusable,106.08,68,,84.86,Percent of Total Billed Charges,68% of Total Billed Charges,118.56,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,78,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,101.4,65,,81.12,Percent of Total Billed Charges,65% of Total Billed Charges,117,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,93.6,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,31.82,20.4,,25.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.82,20.4,,25.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.2,118.56,
FARXIGA 10 MG TAB,631999,CDM,250,RC,,,Outpatient,10,ME,111,77.7,,,,,,Other,Not Seperately Reimbusable,75.48,68,,60.38,Percent of Total Billed Charges,68% of Total Billed Charges,84.36,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,55.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,72.15,65,,57.72,Percent of Total Billed Charges,65% of Total Billed Charges,83.25,75,,66.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.2,20,,17.76,Percent of Total Billed Charges,20% of Total Billed Charges,66.6,60,,53.28,Percent of Total Billed Charges,60% of Total Billed Charges,22.64,20.4,,18.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.64,20.4,,18.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,22.2,20,,17.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.2,20,,17.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.2,84.36,
NAPROXEN 375MG TAB,632000,CDM,250,RC,,,Outpatient,375,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NAPROXEN 500MG -TAB,632020,CDM,250,RC,,,Outpatient,500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,222.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
NARCAN 0.02MG INJ,632050,CDM,250,RC,J2310,HCPCS,Outpatient,2,ME,14,9.8,,8.02,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NASONEX NASAL SPRAY 50MCG,632105,CDM,250,RC,Y7506,HCPCS,Outpatient,,,413,289.1,,,,,,Other,Not Seperately Reimbusable,280.84,68,,224.67,Percent of Total Billed Charges,68% of Total Billed Charges,313.88,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,206.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,313.88,
NASACORT 10GM-INHALER,632108,CDM,250,RC,Y7506,HCPCS,Outpatient,,,318,222.6,,,,,,Other,Not Seperately Reimbusable,216.24,68,,172.99,Percent of Total Billed Charges,68% of Total Billed Charges,241.68,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,159,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159,241.68,
NASACORT AQ 16.5 GM -INHALER,632110,CDM,250,RC,Y7506,HCPCS,Outpatient,,,398,278.6,,,,,,Other,Not Seperately Reimbusable,270.64,68,,216.51,Percent of Total Billed Charges,68% of Total Billed Charges,302.48,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,199,50,,214,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199,302.48,
NASALCROM AEROSOL,632128,CDM,250,RC,Y7506,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,664.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
NEOMY/POLYM/BACIT OPTH OINTMEN,632530,CDM,250,RC,Y7506,HCPCS,Outpatient,,,210,147,,,,,,Other,Not Seperately Reimbusable,142.8,68,,114.24,Percent of Total Billed Charges,68% of Total Billed Charges,159.6,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,105,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,159.6,
NEOMYCIN SUL 500MG TAB,632550,CDM,250,RC,,,Outpatient,500,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
TRIPLE ANITBIOTIC OINT,632650,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1022.72,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TRIPLE ANTIBIOTIC 15G OINT,632700,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TRIPLE DYE,632750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
NEOSPORIN 10CC EYE,632850,CDM,250,RC,Y7506,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
NEOSPORIN 3.5G OPTH EYE,632900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
NEOSPORIN GU IRR 1ML INJ,633006,CDM,250,RC,Y7506,HCPCS,Outpatient,1,ML,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
PHENYLEPHRINE 10MG PO,633050,CDM,250,RC,,,Outpatient,10,ME,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,150.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
NEOSYNEPHRINE 0.25%/15ML-NASAL,633056,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,111.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
NEURONTIN 100MG-CAP,633146,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NEURONTIN 400MG CAPSULE,633147,CDM,250,RC,,,Outpatient,400,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
NEUTRAPHOS PK,633149,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
NEW BORN PHARM CHG,633150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
NEWSKIN SPRAY,633160,CDM,250,RC,Y7506,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,302,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
NEXIUM 40MG IV,633165,CDM,250,RC,Y7507,HCPCS,Outpatient,40,ME,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.5,104.12,
NEVANAC 0.1% 3ML OPHTHALMIC,633170,CDM,250,RC,Y7509,HCPCS,Outpatient,13,ML,615,430.5,,,,,,Other,Not Seperately Reimbusable,418.2,68,,334.56,Percent of Total Billed Charges,68% of Total Billed Charges,467.4,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,307.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.5,467.4,
NEURONTIN 300MG  CAP,633172,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,697.41,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NEXTERONE 150MG/100ML IV,633175,CDM,250,RC,,,Outpatient,150,ME,173,121.1,,,,,,Other,Not Seperately Reimbusable,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,639.2,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,112.45,65,,89.96,Percent of Total Billed Charges,65% of Total Billed Charges,129.75,75,,103.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.6,20,,27.68,Percent of Total Billed Charges,20% of Total Billed Charges,103.8,60,,83.04,Percent of Total Billed Charges,60% of Total Billed Charges,35.29,20.4,,28.23,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.29,20.4,,28.23,Percent of Total Billed Charges,20.4% of Total Billed Charges,34.6,20,,27.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.6,20,,27.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.6,131.48,
NEXTERONE 360MG/200ML IV,633180,CDM,250,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,1022.72,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
NIACIN 100MG TAB,633200,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,652.8,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NIASPAN E.R. 500MG TAB,633225,CDM,250,RC,,,Outpatient,500,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1022.72,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
NICOTINE GUM 4MG,633251,CDM,250,RC,,,Outpatient,4,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1022.72,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
NICOTINE TRANSDERMAL 14MG,633252,CDM,250,RC,Y7506,HCPCS,Outpatient,14,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
NICOTINE TRANSDERMAL 21MG,633253,CDM,250,RC,Y7506,HCPCS,Outpatient,21,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,652.8,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NICOTINE TRANSDERMAL 7MG,633254,CDM,250,RC,Y7506,HCPCS,Outpatient,7,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NIFEREX 50MG TAB,633279,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,761.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NIFEREX 150MG CAP,633282,CDM,250,RC,,,Outpatient,150,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,652.8,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NITRAZINE PAPER NA OTHER,633344,CDM,250,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,639.2,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
NITRO SPRAY ORAL,633348,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
NITROGLYCERIN ER 2.5MG CAP,633350,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,139.26,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,117.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NITROGLYCERIN 6.5MG CAP,633400,CDM,250,RC,,,Outpatient,65,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,815.46,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
NITRODUR 0.1MG/HR-PATCH,633413,CDM,250,RC,Y7506,HCPCS,Outpatient,1,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,815.46,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
NITRO-DUR .3MG/HR PATCH,633414,CDM,250,RC,Y7506,HCPCS,Outpatient,3,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,903.58,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NIRTO-DUR 0.4MG/HR PATCH,633415,CDM,250,RC,Y7506,HCPCS,Outpatient,4,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,1022.72,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
NITRO-DUR 0.2MG/HR PATCH,633434,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
NITROGLYCERINE 2% OINTMENT,633516,CDM,250,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
NITROGLYCERIN 0.6MG/HR PATCH,633528,CDM,250,RC,Y7506,HCPCS,Outpatient,6,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NITROGLYCERIN 30G 01 OINT,633550,CDM,250,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NITROPRUSSIDE 50MG INJ,633553,CDM,250,RC,,,Outpatient,50,ME,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,65,,22.36,Percent of Total Billed Charges,65% of Total Billed Charges,32.25,75,,25.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,32.68,
NITROGLYCERIN 30 GRAMS OINT,633573,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
NITROLINGUAL SPRAY 0.4MG-ORAL,633577,CDM,250,RC,Y7506,HCPCS,Outpatient,4,ME,197,137.9,,,,,,Other,Not Seperately Reimbusable,133.96,68,,107.17,Percent of Total Billed Charges,68% of Total Billed Charges,149.72,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,98.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.5,149.72,
NITROSTAT TAB 0.4MG,633580,CDM,250,RC,,,Outpatient,4,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,370.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NITROGLYCERIN 400MCG/ML INJ,633590,CDM,250,RC,,,Outpatient,400,ML,113,79.1,,,,,,Other,Not Seperately Reimbusable,76.84,68,,61.47,Percent of Total Billed Charges,68% of Total Billed Charges,85.88,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,56.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,73.45,65,,58.76,Percent of Total Billed Charges,65% of Total Billed Charges,84.75,75,,67.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.6,20,,18.08,Percent of Total Billed Charges,20% of Total Billed Charges,67.8,60,,54.24,Percent of Total Billed Charges,60% of Total Billed Charges,23.05,20.4,,18.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.05,20.4,,18.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,22.6,20,,18.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.6,20,,18.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.6,85.88,
NIZORAL CREAM 2%,633624,CDM,250,RC,Y7506,HCPCS,Outpatient,,,98,68.6,,,,,,Other,Not Seperately Reimbusable,66.64,68,,53.31,Percent of Total Billed Charges,68% of Total Billed Charges,74.48,76,,466.75,Percent of Total Billed Charges,76% of Total Billed Charges,49,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,74.48,
NIZORAL 200MG TAB,633625,CDM,250,RC,,,Outpatient,200,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
NIZORAL SHAMPOO 2%,633626,CDM,250,RC,Y7506,HCPCS,Outpatient,,,165,115.5,,,,,,Other,Not Seperately Reimbusable,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,125.4,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,82.5,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.5,125.4,
NOLVADEX 10MG TAB,633650,CDM,250,RC,,,Outpatient,10,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
ORAJEL BABY,633700,CDM,250,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,218.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
NORCO 10MG/350MG -TAB,633729,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
NORCURON  20ML-INJ,633732,CDM,250,RC,,,Outpatient,20,ML,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
ORPHENADRINE CITRATE 100MG-TAB,633745,CDM,250,RC,,,Outpatient,100,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
NORGESIC FORTE 50/770/60MG -TA,633750,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
NORMODYNE 100MG-TAB,633780,CDM,250,RC,,,Outpatient,100,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
ORTHO TRI-CYCLEN 28 TAB,633850,CDM,250,RC,,,Outpatient,,,225,157.5,,,,,,Other,Not Seperately Reimbusable,153,68,,122.4,Percent of Total Billed Charges,68% of Total Billed Charges,171,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,112.5,50,,552.8,Percent of Total Billed Charges,50% of Total Billed Charges,146.25,65,,117,Percent of Total Billed Charges,65% of Total Billed Charges,168.75,75,,135,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,135,60,,108,Percent of Total Billed Charges,60% of Total Billed Charges,45.9,20.4,,36.72,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.9,20.4,,36.72,Percent of Total Billed Charges,20.4% of Total Billed Charges,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,20,,36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45,171,
NORTRIPTYLINE 50MG CAPSULE,633882,CDM,250,RC,,,Outpatient,50,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
NORVASC 10MG-TAB,633890,CDM,250,RC,,,Outpatient,10,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
NORVASC 5MG -TAB,634210,CDM,250,RC,,,Outpatient,5,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
NOVOLIN N 100U/ML INJECTION,634215,CDM,250,RC,J1815,HCPCS,Outpatient,100,ML,16,11.2,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
NOVOLIN 70/30U/ML INJECTION,634216,CDM,250,RC,J1815,HCPCS,Outpatient,7030,ML,16,11.2,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
NOVOLIN R 100U/ML-INJ,634217,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ML,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
NUPERCANIAL OINTMENT,634425,CDM,250,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
"NYSTATIN OINT  100,000 U/GM",634465,CDM,250,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,1222,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
"NYSTATIN POWDER 100,000 U/GM",634466,CDM,250,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,1222,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
NYSTATIN SUSP 5ML,634467,CDM,250,RC,,,Outpatient,5,ML,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,1222,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
"NYSTATIN CREAM 100,000 U/GM",634468,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
OCUFEN .03% -EYE,634470,CDM,250,RC,Y7506,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
OGEN 2.5 1.5MG -TAB,634480,CDM,250,RC,,,Outpatient,2515,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
OGEN 2.5 3MG-TAB,634485,CDM,250,RC,,,Outpatient,253,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
OMNICEF 300MG CAP,634825,CDM,250,RC,,,Outpatient,300,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,190.4,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
OMNICEF SUSP 5ML,634850,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
TOLBUTAMIDE 500MG -TAB,634900,CDM,250,RC,,,Outpatient,500,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
KETPPROFEN 75MG -CAP,634987,CDM,250,RC,,,Outpatient,75,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
OPCON-A-EYE,634990,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ORUVAIL 100MG-CAP,634996,CDM,250,RC,,,Outpatient,100,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
OYSTER SHELL CALCIUM 500MG  TA,635000,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
OSMOPREP 30 TAB KIT,635005,CDM,250,RC,,,Outpatient,,,246,172.2,,,,,,Other,Not Seperately Reimbusable,167.28,68,,133.82,Percent of Total Billed Charges,68% of Total Billed Charges,186.96,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,123,50,,175.6,Percent of Total Billed Charges,50% of Total Billed Charges,159.9,65,,127.92,Percent of Total Billed Charges,65% of Total Billed Charges,184.5,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,147.6,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,50.18,20.4,,40.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.18,20.4,,40.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.2,186.96,
OCEAN NASAL SPRAY 0.65%,635010,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
OXAZEPAM 10MG,635045,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
OXAZEPAM 15MG TABLET,635050,CDM,250,RC,,,Outpatient,15,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
OXISTAT 1% CREAM,635131,CDM,250,RC,Y7506,HCPCS,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
OXISTAT 30ML LOTION,635132,CDM,250,RC,Y7506,HCPCS,Outpatient,30,ML,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
OXYCODONE IR 5MG TAB,635135,CDM,250,RC,,,Outpatient,5,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
OXYBUTYNIN CHLORIDE 5MG/5ML SY,635136,CDM,250,RC,,,Outpatient,55,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
OYST-CAL-D 500MG TAB,635138,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
OXYCONTIN 10MG TABLET,635140,CDM,250,RC,,,Outpatient,10,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
OXYCONTIN 20MG TABLET,635141,CDM,250,RC,,,Outpatient,20,ME,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,24,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
OXYCONTIN 40MG TABLET,635142,CDM,250,RC,,,Outpatient,40,ME,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
NIACIN S.R. 250MG CAPSULE,635145,CDM,250,RC,,,Outpatient,250,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
NORTRIPYLINE 10MG CAP,635161,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NORTRIPYLINE 25MG CAP,635162,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PANAFIL 6GM OINTMENT,635170,CDM,250,RC,Y7506,HCPCS,Outpatient,,,142,99.4,,,,,,Other,Not Seperately Reimbusable,96.56,68,,77.25,Percent of Total Billed Charges,68% of Total Billed Charges,107.92,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,71,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71,107.92,
PANCREASE CAP,635177,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PANTOPRAZOLE 40MG TABLET,635191,CDM,250,RC,,,Outpatient,40,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PARLODEL 2.5MG TAB,635400,CDM,250,RC,,,Outpatient,25,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
PATANOL 0.1% SUSP -EYE,635425,CDM,250,RC,Y7506,HCPCS,Outpatient,,,412,288.4,,,,,,Other,Not Seperately Reimbusable,280.16,68,,224.13,Percent of Total Billed Charges,68% of Total Billed Charges,313.12,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,206,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206,313.12,
PAPAVERINE 150MG CAP,635550,CDM,250,RC,,,Outpatient,150,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PAVABID HP 300MG CAP,635600,CDM,250,RC,,,Outpatient,300,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,232.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PANCURONIUM 2MG/CC  INJ,635650,CDM,250,RC,,,Outpatient,2,ME,116,81.2,,,,,,Other,Not Seperately Reimbusable,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,88.16,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,58,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,75.4,65,,60.32,Percent of Total Billed Charges,65% of Total Billed Charges,87,75,,69.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,69.6,60,,55.68,Percent of Total Billed Charges,60% of Total Billed Charges,23.66,20.4,,18.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.66,20.4,,18.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.2,20,,18.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.2,88.16,
PAXIL 20MG  TAB,635661,CDM,250,RC,,,Outpatient,20,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,115.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
PCN G 1MIL U INJ,635950,CDM,250,RC,J2540,HCPCS,Outpatient,,,59,41.3,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,44.84,
PCN G 2 MIL U INJ,636000,CDM,250,RC,J2540,HCPCS,Outpatient,,,88,61.6,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,66.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,44,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44,66.88,
PENICILLIN G POTASSIUM 2MILL U,636145,CDM,250,RC,Y7507,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
PENICILLIN-VK 250MG -TAB,636150,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PENICILLIN-VK 125MG/5ML-SUSP,636245,CDM,250,RC,,,Outpatient,1255,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PCN VK 250MG/100ML-SUSP,636295,CDM,250,RC,,,Outpatient,250,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
PEDIA CARE COUGH/COLD 120ML SU,636296,CDM,250,RC,,,Outpatient,120,ML,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PEDICARE DECONG 7.5MG/2.5MG-LI,636297,CDM,250,RC,,,Outpatient,7525,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PENTASA 250MG,636350,CDM,250,RC,,,Outpatient,250,ME,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,10.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
PEDIAPRED 6.7MG/5ML-LIQ,636351,CDM,250,RC,,,Outpatient,675,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
PEDIAZOLE 200MG/600MG/5ML-LIQ,636353,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PEDIAZOLE 200/600 5M -LIQ,636354,CDM,250,RC,,,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
PEPCID 20 MG-TAB,636430,CDM,250,RC,,,Outpatient,20,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
PEPCID 400MG/5ML SUSPENSION,636435,CDM,250,RC,,,Outpatient,4005,ME,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.3,65,,32.24,Percent of Total Billed Charges,65% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,37.2,60,,29.76,Percent of Total Billed Charges,60% of Total Billed Charges,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.65,20.4,,10.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.4,20,,9.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.4,47.12,
PINK BISMUTH TABLETS,636437,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PINK BISMUTH 4 OZ -LIQ,636438,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PERCOCET 5/325MG TABLET,636446,CDM,250,RC,,,Outpatient,5325,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PERCOCET 10/325MG TABLET,636450,CDM,250,RC,S5001,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DOCUSATE SODIUM W/CASANT-CAP,636550,CDM,250,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
CYPROHEPTADINE HCL 4MG-TAB,636650,CDM,250,RC,,,Outpatient,4,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CYPROHEPTADINE 2MG/5ML-LIQ,636700,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.95,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIPYRIDAMOLE 25MG TAB,636900,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
WHITE PETROLATUM 1OZ-OINT,636950,CDM,250,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
PHARMACY ADD FEE,637000,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENAZOPYRIDINE HCL 200MG TABL,637100,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENAZOPYRIDINE HCL 200MG TABL,637200,CDM,250,RC,,,Outpatient,200,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
PHENERGAN DM SYRUP,637325,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENERGAN EXP 5ML-LIQ,637350,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PHENERGAN EX W/COD 5 -LIQ,637400,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROMETH W/CODEINE COUGH 6.25MG,637402,CDM,250,RC,,,Outpatient,625,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,338.91,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PHENERGAN 12.5MG SUPP,637650,CDM,250,RC,Y7506,HCPCS,Outpatient,125,ME,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
PHENERGAN 25MG SUPP,637700,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
PHENERGAN 25MG TAB,637850,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,291.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENOBARBITAL 32.4MG TAB,637950,CDM,250,RC,,,Outpatient,324,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,903.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENOBARB 30MG/7.5ML-LIQ,638100,CDM,250,RC,,,Outpatient,3075,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENYTEK 200MG CAP,638225,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENYTEK 300MG CAP,638240,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHENOL LIQUEFIED,638252,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PHENYLEPHRINE HCL OPHTHAL 2.5%,638253,CDM,250,RC,Y7506,HCPCS,Outpatient,,,163,114.1,,,,,,Other,Not Seperately Reimbusable,110.84,68,,88.67,Percent of Total Billed Charges,68% of Total Billed Charges,123.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,81.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.5,123.88,
PHENTERMINE 30MG TABLET,638254,CDM,250,RC,,,Outpatient,30,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHOSLO 667MG TABLET,638265,CDM,250,RC,,,Outpatient,667,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,204.54,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PHYSOSTIGMINE 1MG/ML INJECTION,638267,CDM,250,RC,,,Outpatient,1,ME,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,151.78,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,78,65,,62.4,Percent of Total Billed Charges,65% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,72,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,91.2,
PILOCAR 6%-EYE,638403,CDM,250,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
PILOCARPINE HC 4% GEL-EYE,638404,CDM,250,RC,Y7506,HCPCS,Outpatient,,,182,127.4,,,,,,Other,Not Seperately Reimbusable,123.76,68,,99.01,Percent of Total Billed Charges,68% of Total Billed Charges,138.32,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,91,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,138.32,
PILOCARPINE 1% GTTS-15ML,638405,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,379,265.3,,,,,,Other,Not Seperately Reimbusable,257.72,68,,206.18,Percent of Total Billed Charges,68% of Total Billed Charges,288.04,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,189.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.5,288.04,
PILOCARPINE 2% 15ML EYE DROPS,638406,CDM,250,RC,,,Outpatient,5,ML,125,87.5,,,,,,Other,Not Seperately Reimbusable,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,39.17,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,81.25,65,,65,Percent of Total Billed Charges,65% of Total Billed Charges,93.75,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,75,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,95,
PIPERACILLIN 2GM INJ,638424,CDM,250,RC,J2543,HCPCS,Outpatient,,,55,38.5,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,160,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
PIPERACILLIN 3GM INJ,638426,CDM,250,RC,J2543,HCPCS,Outpatient,,,80,56,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,160,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
PIPERACILLIN 4GM INJ,638428,CDM,250,RC,J2543,HCPCS,Outpatient,,,105,73.5,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,93.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
CEBOCAP (ORANGE) CAP,638460,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PLAN B ONE STEP 1.5MG TAB,638463,CDM,250,RC,,,Outpatient,15,ME,156,109.2,,,,,,Other,Not Seperately Reimbusable,106.08,68,,84.86,Percent of Total Billed Charges,68% of Total Billed Charges,118.56,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,78,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,101.4,65,,81.12,Percent of Total Billed Charges,65% of Total Billed Charges,117,75,,93.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,93.6,60,,74.88,Percent of Total Billed Charges,60% of Total Billed Charges,31.82,20.4,,25.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.82,20.4,,25.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.2,20,,24.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.2,118.56,
PLASMA 500MG IV INJ,638465,CDM,250,RC,Y7506,HCPCS,Outpatient,500,ME,380,266,,,,,,Other,Not Seperately Reimbusable,258.4,68,,206.72,Percent of Total Billed Charges,68% of Total Billed Charges,288.8,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,190,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190,288.8,
PLAQUENIL 200MG TABLET,638468,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PLAVIX 75MG-TAB,638470,CDM,250,RC,,,Outpatient,75,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
PLENDIL 2.5MG-TAB,638471,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,95.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PLENDIL 5MG-TAB,638472,CDM,250,RC,,,Outpatient,5,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PLETAL 100MG-TAB,638473,CDM,250,RC,,,Outpatient,100,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
POLYHISTINE CS 5ML-LIQ,638480,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
POLY-VI-FLOR W/IRON 0.5MG -LIQ,638547,CDM,250,RC,,,Outpatient,5,ME,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
POLY-VI-SOL W/FE DRP-LIQ,638600,CDM,250,RC,,,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
POLY-VI-SOL DROPS,638625,CDM,250,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
POLYHISTINE 5ML ELIX -LIQ,638650,CDM,250,RC,,,Outpatient,5,ML,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
POLYHISTINE 5ML EXP-LIQ,638700,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
TRIHIST-DM 12.5/2/10MG-LIQ,638750,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,178.75,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
POLY D 10ML-LIQ,638754,CDM,250,RC,,,Outpatient,10,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
"POLYMYXIN B 500,000 UNITS INJE",638875,CDM,250,RC,,,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,65,,30.16,Percent of Total Billed Charges,65% of Total Billed Charges,43.5,75,,34.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,34.8,60,,27.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,44.08,
POLYSPORIN 15G OINT -EYE,638900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
POLYSPORIN 3.5G OPTH OINTMENT-,638905,CDM,250,RC,Y7506,HCPCS,Outpatient,,,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
POLYTRIM OPHT 10ML-EYE,638912,CDM,250,RC,Y7506,HCPCS,Outpatient,10,ML,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,31.16,
POLYTRIM-EYE,638920,CDM,250,RC,Y7506,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
PONTOCAINE EYE,638940,CDM,250,RC,Y7506,HCPCS,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
PONTOCAINE 3.5G OPTH-EYE,638950,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
PONTOCAINE 20MG/2ML INJ,638960,CDM,250,RC,,,Outpatient,202,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
TETRACAINE 1/2% -EYE,639000,CDM,250,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
POTASSIUM CHLORIDE 40MEQ/15ML-,639150,CDM,250,RC,,,Outpatient,5,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
POTASSIUM CHLORIDE 20MEQ/15ML,639175,CDM,250,RC,,,Outpatient,5,ML,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,28.6,65,,22.88,Percent of Total Billed Charges,65% of Total Billed Charges,33,75,,26.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,26.4,60,,21.12,Percent of Total Billed Charges,60% of Total Billed Charges,8.98,20.4,,7.18,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.98,20.4,,7.18,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.8,33.44,
POTASSIUM PHOSPHATES 45MM INJ,639212,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
PRADAXA 75MG CAP,639215,CDM,250,RC,,,Outpatient,75,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,503.74,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
PRADAXA 150MG CAP,639220,CDM,250,RC,,,Outpatient,150,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
PRANDIN 0.5MG-TAB,639254,CDM,250,RC,,,Outpatient,5,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PRANDIN 1MG TABLET,639255,CDM,250,RC,,,Outpatient,1,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PRANDIN 2MG-CAP,639256,CDM,250,RC,,,Outpatient,2,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PRAVACHOL 10MG-TAB,639261,CDM,250,RC,,,Outpatient,10,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
PRAVACHOL 20MG-TAB,639263,CDM,250,RC,,,Outpatient,20,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,297.57,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
PRECEDEX 200MCG/2ML INJ,639275,CDM,250,RC,Y7506,HCPCS,Outpatient,2002,ML,363,254.1,,,,,,Other,Not Seperately Reimbusable,246.84,68,,197.47,Percent of Total Billed Charges,68% of Total Billed Charges,275.88,76,,338.91,Percent of Total Billed Charges,76% of Total Billed Charges,181.5,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.5,275.88,
PRECOSE 50MG-TAB,639281,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRECOSE 100MG-TAB,639283,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRE-PEN TOPICAL,639286,CDM,250,RC,Y7506,HCPCS,Outpatient,,,124,86.8,,,,,,Other,Not Seperately Reimbusable,84.32,68,,67.46,Percent of Total Billed Charges,68% of Total Billed Charges,94.24,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,62,50,,32.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,94.24,
PRED FORTE 1% 5ML OP-EYE,639300,CDM,250,RC,Y7506,HCPCS,Outpatient,15,ML,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
PREDNISOLNE 15MG/5ML SYRUP,639330,CDM,250,RC,,,Outpatient,155,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PREDNISONE 1MG-TAB,639348,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREDNISONE 5MG TAB,639350,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREDNISONE 10MG TAB,639400,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREDNISONE 20MG TAB,639450,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREDNISOLONE 5MG/5ML SYRUP 120,639511,CDM,250,RC,,,Outpatient,,,161,112.7,,,,,,Other,Not Seperately Reimbusable,109.48,68,,87.58,Percent of Total Billed Charges,68% of Total Billed Charges,122.36,76,,180.61,Percent of Total Billed Charges,76% of Total Billed Charges,80.5,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,104.65,65,,83.72,Percent of Total Billed Charges,65% of Total Billed Charges,120.75,75,,96.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,96.6,60,,77.28,Percent of Total Billed Charges,60% of Total Billed Charges,32.84,20.4,,26.27,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.84,20.4,,26.27,Percent of Total Billed Charges,20.4% of Total Billed Charges,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.2,20,,25.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.2,122.36,
PRELONE SYRUP 5MG,639529,CDM,250,RC,,,Outpatient,5,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
PREPARATION H 28G SUPP,639530,CDM,250,RC,,,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
PREMARIN 0.3MG-CAP,639543,CDM,250,RC,,,Outpatient,3,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREMARIN 0.9MG-CAP,639544,CDM,250,RC,,,Outpatient,9,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PREMARIN .625MG TAB,639550,CDM,250,RC,,,Outpatient,625,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREMARIN 1.25MG TAB,639600,CDM,250,RC,,,Outpatient,125,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PREMARIN 0.625MG CREAM 30GM,639700,CDM,250,RC,Y7506,HCPCS,Outpatient,,,385,269.5,,,,,,Other,Not Seperately Reimbusable,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,292.6,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,192.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.5,292.6,
PREMPHASE 0.625MG/5MG-TAB,639701,CDM,250,RC,,,Outpatient,6255,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,338.91,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,213.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PREMPRO 0.625MG/2.5MG-TAB,639702,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,93.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PREMPRO 0.625MG/5MG-TAB,639703,CDM,250,RC,,,Outpatient,6255,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PREPIDIL GEL 0.5MG,639705,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ME,989,692.3,,,,,,Other,Not Seperately Reimbusable,672.52,68,,538.02,Percent of Total Billed Charges,68% of Total Billed Charges,751.64,76,,1661.92,Percent of Total Billed Charges,76% of Total Billed Charges,494.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,494.5,751.64,
PREVACID 30MG-SPRK PKG,639707,CDM,250,RC,,,Outpatient,30,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,1661.92,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
PREVACID 30MG-CAP,639708,CDM,250,RC,,,Outpatient,30,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,76.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
PREVNAR 0.5ML INJECTION,639709,CDM,250,RC,,,Outpatient,5,ML,390,273,,,,,,Other,Not Seperately Reimbusable,265.2,68,,212.16,Percent of Total Billed Charges,68% of Total Billed Charges,296.4,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,195,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.5,65,,202.8,Percent of Total Billed Charges,65% of Total Billed Charges,292.5,75,,234,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78,20,,62.4,Percent of Total Billed Charges,20% of Total Billed Charges,234,60,,187.2,Percent of Total Billed Charges,60% of Total Billed Charges,79.56,20.4,,63.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.56,20.4,,63.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,78,20,,62.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78,20,,62.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78,296.4,
PREMESIS RX 1MG TABLET,639710,CDM,250,RC,,,Outpatient,1,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PREVACID 30MG-SOLUTAB,639711,CDM,250,RC,,,Outpatient,30,ME,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
PREVNAR 13 INJ,639712,CDM,250,RC,,,Outpatient,,,645,451.5,,,,,,Other,Not Seperately Reimbusable,438.6,68,,350.88,Percent of Total Billed Charges,68% of Total Billed Charges,490.2,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,322.5,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,419.25,65,,335.4,Percent of Total Billed Charges,65% of Total Billed Charges,483.75,75,,387,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,387,60,,309.6,Percent of Total Billed Charges,60% of Total Billed Charges,131.58,20.4,,105.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,131.58,20.4,,105.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,129,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,129,490.2,
PRIMIDONE 250MG TAB,639719,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,110.98,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRENATAL RX-TAB,639722,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREPARATION H OINT,639724,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PRILOSEC 20MG-CAP,639725,CDM,250,RC,,,Outpatient,20,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,912,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
LISONPRIL 20MG TAB,639726,CDM,250,RC,,,Outpatient,20,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRINIVIL 10MG-TAB,639727,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,266.91,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRINIVIL 5MG-TAB,639728,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRILOSEC 10MG-CAP,639729,CDM,250,RC,,,Outpatient,10,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
PRINCIPEN 125MG/ML SUSPENSION,639730,CDM,250,RC,,,Outpatient,125,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PRINZIDE 20-12.5MG-TAB,639735,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PREVACID 15MG-CAP,639740,CDM,250,RC,,,Outpatient,15,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
PROBANTHINE 7.5MG TAB,639798,CDM,250,RC,,,Outpatient,75,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
PROPANTHELINE 15MG-TAB,639800,CDM,250,RC,,,Outpatient,15,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,237.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROPARACAINE 0.5% EYE DROP,639825,CDM,250,RC,Y7506,HCPCS,Outpatient,,,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
PROCAINAMIDE HCI 750MG-TAB,639890,CDM,250,RC,,,Outpatient,750,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
POCANBID 1000MG-TAB,639898,CDM,250,RC,,,Outpatient,1000,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
NIFEDIPINE 10MG CAPSULE,640060,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROCARDIA XL 60MG SLOW RELEASE,640062,CDM,250,RC,,,Outpatient,60,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
PROCARDIA XL 90MG-TAB,640064,CDM,250,RC,,,Outpatient,90,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
PROCARDIA XL 30MG-TAB,640065,CDM,250,RC,,,Outpatient,30,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
PROCARDIA XL 60MG-TAB,640066,CDM,250,RC,,,Outpatient,60,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
PROCTOFOAM 1%,640068,CDM,250,RC,Y7506,HCPCS,Outpatient,,,278,194.6,,,,,,Other,Not Seperately Reimbusable,189.04,68,,151.23,Percent of Total Billed Charges,68% of Total Billed Charges,211.28,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,139,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139,211.28,
PROCTOCORT 30MG SUPP,640069,CDM,250,RC,Y7506,HCPCS,Outpatient,30,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
PROFEN II 37.5MG-600MG-TAB,640082,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PROFENAL OPTHALMIC 1%,640084,CDM,250,RC,Y7506,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
PROGESTERONE 50MG/ML X 10ML VI,640100,CDM,250,RC,J2675,HCPCS,Outpatient,5010,ME,57,39.9,,1.01,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
PROGESTERONE 100 MG CAP,640111,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROLEX D 20MG/600MG TAB,640145,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,353.25,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROLEX DM SYRUP,640150,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
FLUPHENAZINE HCL 5MG/ML ORAL C,640154,CDM,250,RC,,,Outpatient,5,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROGRAF 0.5MG CAP,640180,CDM,250,RC,,,Outpatient,5,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
PROMETH 6.25MG-LIQ,640194,CDM,250,RC,,,Outpatient,625,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,138,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROMETHAZINE/CODEINE 6.25MG/10,640195,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PRONESTYL 250MG CAP,640200,CDM,250,RC,,,Outpatient,250,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PROCAINAMIDE 500MG-TAB,640300,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROPINE OPTH 1% -EYE,640380,CDM,250,RC,Y7506,HCPCS,Outpatient,,,132,92.4,,,,,,Other,Not Seperately Reimbusable,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,100.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,66,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66,100.32,
PROPULSID 10MG-TAB,640417,CDM,250,RC,,,Outpatient,10,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
PROPULSID 1MG/ML-LIQ,640421,CDM,250,RC,,,Outpatient,1,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROPYLTHIOURACIL 50MG TABLET,640425,CDM,250,RC,,,Outpatient,50,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROMETH VC PLAIN SUSPENSION,640426,CDM,250,RC,,,Outpatient,,,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,75,,35.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,35.4,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.8,44.84,
PROSCAR 5MG TAB,640429,CDM,250,RC,,,Outpatient,5,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
NEOSTIGMINE METHYLSULFATE 10MG,640450,CDM,250,RC,,,Outpatient,10,ME,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,21,75,,16.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.6,21.28,
NEPHROVITE RX-TAB,640460,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROSTIN E2 20MG-SUPP,640474,CDM,250,RC,Y7506,HCPCS,Outpatient,220,ME,3820,2674,,,,,,Other,Not Seperately Reimbusable,2597.6,68,,2078.08,Percent of Total Billed Charges,68% of Total Billed Charges,2903.2,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,1910,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1910,2903.2,
PROTAMIN SULF 5ML INJ,640500,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
PROTEGRA-PO,640512,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROTONIX 20MG TAB,640516,CDM,250,RC,,,Outpatient,20,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
PROTONIX 40MG INJ,640518,CDM,250,RC,,,Outpatient,40,ME,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,104,65,,83.2,Percent of Total Billed Charges,65% of Total Billed Charges,120,75,,96,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,96,60,,76.8,Percent of Total Billed Charges,60% of Total Billed Charges,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.64,20.4,,26.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,20,,25.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32,121.6,
PROTONIX 40MG SUSP ORAL,640519,CDM,250,RC,,,Outpatient,40,ME,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,24,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
PLASMA PROTEIN FRACTION 5% INJ,640523,CDM,250,RC,P9018,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,127.68,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,84,50,,0.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,127.68,
ALBUTEROL INHALATION 17GRAMS,640590,CDM,250,RC,,,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,126.4,Percent of Total Billed Charges,50% of Total Billed Charges,103.35,65,,82.68,Percent of Total Billed Charges,65% of Total Billed Charges,119.25,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,95.4,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,32.44,20.4,,25.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.44,20.4,,25.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.8,120.84,
ALBUTEROL 4MG-TAB,640592,CDM,250,RC,,,Outpatient,4,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ALBUTEROL 2MG/5ML-LIQ,640593,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROVENTIL REPETABS 4MG-TAB,640596,CDM,250,RC,,,Outpatient,4,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROVERA 2.5MG-TAB,640598,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROVERA 5MG-TAB,640599,CDM,250,RC,,,Outpatient,5,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PROZAC 10MG-CAP,640613,CDM,250,RC,,,Outpatient,10,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
PROZAC 20MG-CAP,640614,CDM,250,RC,,,Outpatient,20,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
PYRAZINAMIDE 500MG TAB,640630,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PSCORN E  0.05%,640635,CDM,250,RC,,,Outpatient,,,214,149.8,,,,,,Other,Not Seperately Reimbusable,145.52,68,,116.42,Percent of Total Billed Charges,68% of Total Billed Charges,162.64,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,139.1,65,,111.28,Percent of Total Billed Charges,65% of Total Billed Charges,160.5,75,,128.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.8,20,,34.24,Percent of Total Billed Charges,20% of Total Billed Charges,128.4,60,,102.72,Percent of Total Billed Charges,60% of Total Billed Charges,43.66,20.4,,34.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,43.66,20.4,,34.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,42.8,20,,34.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.8,20,,34.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,42.8,162.64,
PYRIDOSTIGMINE 60MG TAB,640640,CDM,250,RC,,,Outpatient,60,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
PHENAZOPYRIDINE 100MG-CAP,640650,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PSEUDOEPHEDRINE/GUAIFENES 120M,640655,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
PSEUDOVENT 250MG/120MG CAPSULE,640660,CDM,250,RC,,,Outpatient,250,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
VITAMIN B-6 50MG-TAB,640750,CDM,250,RC,,,Outpatient,650,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
Q-TUSSIN PE 100MG/30MG-LIQ,640992,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
QUELICN 20MG/ML/50MG-INJ,641000,CDM,250,RC,J0330,HCPCS,Outpatient,2050,ME,5,3.5,,0.79,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
CHOLESTYRAMINE,641050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
QUINAGLUTE 324MG-TAB,641350,CDM,250,RC,,,Outpatient,324,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
QUININE SULFATE 260MG-TAB,641400,CDM,250,RC,,,Outpatient,260,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,332.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
QUINDAL-HD PLUS-LIQ,641410,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
QUINIDEX EXTENTAB 300MG-TAB,641416,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
RANEXA 500MG TAB,641525,CDM,250,RC,,,Outpatient,500,ME,34,23.8,,,,,,Other,Not Seperately Reimbusable,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.1,65,,17.68,Percent of Total Billed Charges,65% of Total Billed Charges,25.5,75,,20.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,20.4,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,6.94,20.4,,5.55,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.94,20.4,,5.55,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.8,25.84,
QUININE 325MG CAP,641550,CDM,250,RC,,,Outpatient,325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
RABAVERT INJ 1ML,641555,CDM,250,RC,,,Outpatient,1,ML,886,620.2,,,,,,Other,Not Seperately Reimbusable,602.48,68,,481.98,Percent of Total Billed Charges,68% of Total Billed Charges,673.36,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,443,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,575.9,65,,460.72,Percent of Total Billed Charges,65% of Total Billed Charges,664.5,75,,531.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.2,20,,141.76,Percent of Total Billed Charges,20% of Total Billed Charges,531.6,60,,425.28,Percent of Total Billed Charges,60% of Total Billed Charges,180.74,20.4,,144.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,180.74,20.4,,144.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,177.2,20,,141.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.2,20,,141.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.2,673.36,
RACEPINEPHRINE 2.25% INHALATIO,641560,CDM,250,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
RANITIDINE 150MG/10ML-LIQ,641567,CDM,250,RC,,,Outpatient,150,ME,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,39,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,31.2,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,39.52,
RAXAR 200MG,641658,CDM,250,RC,Y7506,HCPCS,Outpatient,200,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
METOCLOPRAMIDE 10MG TAB,641712,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
REGLAN SYRUP 5ML,641719,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
REGONAL 25MG-INJ,641730,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ME,124,86.8,,,,,,Other,Not Seperately Reimbusable,84.32,68,,67.46,Percent of Total Billed Charges,68% of Total Billed Charges,94.24,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,62,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,94.24,
RELAFEN 500MG-TAB,641792,CDM,250,RC,,,Outpatient,500,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
RELAFEN 750MG-TAB,641794,CDM,250,RC,,,Outpatient,750,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
RELENZA 5MG INH,641796,CDM,250,RC,,,Outpatient,5,ME,296,207.2,,,,,,Other,Not Seperately Reimbusable,201.28,68,,161.02,Percent of Total Billed Charges,68% of Total Billed Charges,224.96,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,148,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,192.4,65,,153.92,Percent of Total Billed Charges,65% of Total Billed Charges,222,75,,177.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.2,20,,47.36,Percent of Total Billed Charges,20% of Total Billed Charges,177.6,60,,142.08,Percent of Total Billed Charges,60% of Total Billed Charges,60.38,20.4,,48.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60.38,20.4,,48.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,59.2,20,,47.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.2,20,,47.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.2,224.96,
REMINYL 8MG TABLET,641799,CDM,250,RC,,,Outpatient,8,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
REMERON 15MG TAB,641800,CDM,250,RC,,,Outpatient,15,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,144.7,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
REMERON 30MG,641801,CDM,250,RC,,,Outpatient,30,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
RENAGEL 800MG TAB,641809,CDM,250,RC,,,Outpatient,800,ME,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,20.8,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,24,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,19.2,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,6.53,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,6.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
QVAR 40MCG INH,642000,CDM,250,RC,,,Outpatient,,,406,284.2,,,,,,Other,Not Seperately Reimbusable,276.08,68,,220.86,Percent of Total Billed Charges,68% of Total Billed Charges,308.56,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,203,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,263.9,65,,211.12,Percent of Total Billed Charges,65% of Total Billed Charges,304.5,75,,243.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.2,20,,64.96,Percent of Total Billed Charges,20% of Total Billed Charges,243.6,60,,194.88,Percent of Total Billed Charges,60% of Total Billed Charges,82.82,20.4,,66.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.82,20.4,,66.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,81.2,20,,64.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.2,20,,64.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.2,308.56,
QVAR 80MCG INH,642025,CDM,250,RC,,,Outpatient,,,544,380.8,,,,,,Other,Not Seperately Reimbusable,369.92,68,,295.94,Percent of Total Billed Charges,68% of Total Billed Charges,413.44,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,272,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,353.6,65,,282.88,Percent of Total Billed Charges,65% of Total Billed Charges,408,75,,326.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.8,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,326.4,60,,261.12,Percent of Total Billed Charges,60% of Total Billed Charges,110.98,20.4,,88.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,110.98,20.4,,88.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,108.8,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.8,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.8,413.44,
TEMAZEPAM 15MG CAP,642050,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TEMAZEPAM 30MG CAP,642100,CDM,250,RC,,,Outpatient,30,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
REQUIP 0.25MG TAB,642110,CDM,250,RC,,,Outpatient,25,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,134.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
RETAVASE 2X10U-INJ,642124,CDM,250,RC,Y7506,HCPCS,Outpatient,,,7321,5124.7,,,,,,Other,Not Seperately Reimbusable,4978.28,68,,3982.62,Percent of Total Billed Charges,68% of Total Billed Charges,5563.96,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,3660.5,50,,230.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3660.5,5563.96,
REQUIP 1MG TAB,642125,CDM,250,RC,,,Outpatient,1,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,193.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
RHINALL NASAL,642150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
RHINOCORT AQUA 32MCG,642160,CDM,250,RC,,,Outpatient,,,423,296.1,,,,,,Other,Not Seperately Reimbusable,287.64,68,,230.11,Percent of Total Billed Charges,68% of Total Billed Charges,321.48,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,211.5,50,,136.8,Percent of Total Billed Charges,50% of Total Billed Charges,274.95,65,,219.96,Percent of Total Billed Charges,65% of Total Billed Charges,317.25,75,,253.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.6,20,,67.68,Percent of Total Billed Charges,20% of Total Billed Charges,253.8,60,,203.04,Percent of Total Billed Charges,60% of Total Billed Charges,86.29,20.4,,69.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.29,20.4,,69.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,84.6,20,,67.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.6,20,,67.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.6,321.48,
RETROVIR 100MG-CAP,642163,CDM,250,RC,,,Outpatient,100,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
REZULIN 200MG-TAB,642166,CDM,250,RC,,,Outpatient,200,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
RHYTHMOL 225MG-TAB,642170,CDM,250,RC,,,Outpatient,225,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
RIFADIN 300MG CAP,642200,CDM,250,RC,,,Outpatient,300,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
RIFAXIMIN 550MG TAB,642210,CDM,250,RC,,,Outpatient,550,ME,170,119,,,,,,Other,Not Seperately Reimbusable,115.6,68,,92.48,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,85,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,110.5,65,,88.4,Percent of Total Billed Charges,65% of Total Billed Charges,127.5,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,102,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,34.68,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.68,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34,129.2,
RIMANTADINE 100MG,642225,CDM,250,RC,,,Outpatient,100,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
RISPERDAL 1MG-TAB,642381,CDM,250,RC,,,Outpatient,1,ME,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
RISPERDAL 0.25MG-TAB,642383,CDM,250,RC,,,Outpatient,25,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,123.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
RISPERIDONE 0.5MG TAB,642390,CDM,250,RC,,,Outpatient,5,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
RISPERIDONE 4MG TAB,642395,CDM,250,RC,,,Outpatient,4,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
RITALIN 5MG TAB,642400,CDM,250,RC,,,Outpatient,5,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,122.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
RITALIN 10MG TAB,642450,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,65.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
METHOCARBAMOL TAB 500MG,642500,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHOCARBAMOL 750MG-TAB,642550,CDM,250,RC,,,Outpatient,750,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,89.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ROBINUL 1MG INH,642750,CDM,250,RC,J7643,HCPCS,Outpatient,1,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
ROBITUSSIN 5ML SYRUP,642800,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ROBITUSSIN C&C INFANT,642850,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,241.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ROBITUSSIN PED C&C,642875,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ROBITUSSIN PED COUGH/COLD SYRU,642880,CDM,250,RC,,,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,86.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.5,65,,15.6,Percent of Total Billed Charges,65% of Total Billed Charges,22.5,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,22.8,
ROBITUSSIN 120ML SYRUP,642950,CDM,250,RC,,,Outpatient,120,ML,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
ROBITUSSIN DM 5ML LIQ,643200,CDM,250,RC,,,Outpatient,5,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,53.5,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ROBITUSSIN DM DROPS,643250,CDM,250,RC,,,Outpatient,,,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
GUAIFENESIN DM 120ML-TAB,643350,CDM,250,RC,,,Outpatient,120,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ROCALTROL 0.25MCG-TAB,643352,CDM,250,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
SILDEC-DM DROPS-LIQ,643364,CDM,250,RC,,,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,114,
RONDEC DROPS-PO,643365,CDM,250,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
RONDEC SYRUP,643366,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SILDENAFIL 50MG TAB,643380,CDM,250,RC,,,Outpatient,50,ME,86,60.2,,,,,,Other,Not Seperately Reimbusable,58.48,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,65.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,43,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,55.9,65,,44.72,Percent of Total Billed Charges,65% of Total Billed Charges,64.5,75,,51.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,51.6,60,,41.28,Percent of Total Billed Charges,60% of Total Billed Charges,17.54,20.4,,14.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.54,20.4,,14.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.2,20,,13.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.2,65.36,
ROWASA 500MG SUPP,643382,CDM,250,RC,Y7506,HCPCS,Outpatient,500,ME,112,78.4,,,,,,Other,Not Seperately Reimbusable,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,109.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
RYTHMOL 150MG-TAB,643782,CDM,250,RC,,,Outpatient,150,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
SALSALATE 500MG TAB,643818,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SALSALATE 750MG-TAB,643821,CDM,250,RC,,,Outpatient,750,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
SANTYL OINTMENT,643911,CDM,250,RC,Y7506,HCPCS,Outpatient,,,1084,758.8,,,,,,Other,Not Seperately Reimbusable,737.12,68,,589.7,Percent of Total Billed Charges,68% of Total Billed Charges,823.84,76,,101.54,Percent of Total Billed Charges,76% of Total Billed Charges,542,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542,823.84,
SCARLET RED 5X9-TOPICAL,643932,CDM,250,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,88.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
SAPHRIS 5MG TAB,643950,CDM,250,RC,,,Outpatient,5,ME,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,324.06,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,75,,35.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,35.4,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.8,44.84,
SAPHRIS 10MG TAB,643975,CDM,250,RC,,,Outpatient,10,ME,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,146.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,65,,30.16,Percent of Total Billed Charges,65% of Total Billed Charges,43.5,75,,34.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,34.8,60,,27.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,20.4,,9.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,9.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,44.08,
SECONAL 100MG CAP,644150,CDM,250,RC,,,Outpatient,100,ME,165,115.5,,,,,,Other,Not Seperately Reimbusable,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,125.4,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,82.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,107.25,65,,85.8,Percent of Total Billed Charges,65% of Total Billed Charges,123.75,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,99,60,,79.2,Percent of Total Billed Charges,60% of Total Billed Charges,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.66,20.4,,26.93,Percent of Total Billed Charges,20.4% of Total Billed Charges,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,20,,26.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33,125.4,
SENNA PLUS,644280,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SENNA SYRUP,644290,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,39.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SENOKOT TAB,644300,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,57.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SENISPAR 30MG TAB,644325,CDM,250,RC,,,Outpatient,30,ME,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,41.6,65,,33.28,Percent of Total Billed Charges,65% of Total Billed Charges,48,75,,38.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,38.4,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.8,48.64,
SENSORCAINE MPF 0.25% 10ML INJ,644335,CDM,250,RC,,,Outpatient,2510,ML,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
SENSORCAINE MPF 0.75% INJ,644337,CDM,250,RC,,,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
SERENTIL 10MG-TAB,644573,CDM,250,RC,,,Outpatient,10,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
SEREVENT 6.5GM-INHALER,644614,CDM,250,RC,Y7506,HCPCS,Outpatient,,,223,156.1,,,,,,Other,Not Seperately Reimbusable,151.64,68,,121.31,Percent of Total Billed Charges,68% of Total Billed Charges,169.48,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,111.5,50,,45.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.5,169.48,
SEREVENT INHALER 13G,644617,CDM,250,RC,Y7506,HCPCS,Outpatient,,,346,242.2,,,,,,Other,Not Seperately Reimbusable,235.28,68,,188.22,Percent of Total Billed Charges,68% of Total Billed Charges,262.96,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,173,50,,28.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173,262.96,
SEROQUEL 25MG TABLET,644650,CDM,250,RC,,,Outpatient,25,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
SEROQUEL 100MG TAB,644660,CDM,250,RC,,,Outpatient,100,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,136.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
SEROQUEL 200MG TAB,644670,CDM,250,RC,,,Outpatient,200,ME,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,360.54,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
SEROQUEL XR 50MG TAB,644675,CDM,250,RC,,,Outpatient,50,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
SEROQUEL XR 150MG TAB,644677,CDM,250,RC,,,Outpatient,150,ME,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,33.15,65,,26.52,Percent of Total Billed Charges,65% of Total Billed Charges,38.25,75,,30.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,30.6,60,,24.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,38.76,
SEROQUEL XR 200MG TAB,644680,CDM,250,RC,,,Outpatient,200,ME,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,27.56,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,31.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,25.44,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,8.65,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,8.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
SERTRALINE 100MG TABLET,644682,CDM,250,RC,,,Outpatient,100,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
SERZONE 100MG-TAB,644685,CDM,250,RC,,,Outpatient,100,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,341.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
SSD SILVER SULFADIAZINE 25G-OI,644695,CDM,250,RC,Y7506,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
SSD 20GM TUBE-OINT,644698,CDM,250,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,96.06,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
SILVER SULFADIAZINE 50GM-OINT,644700,CDM,250,RC,Y7506,HCPCS,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
SILVER SULFADIAZINE 400GR-OINT,644750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,260,182,,,,,,Other,Not Seperately Reimbusable,176.8,68,,141.44,Percent of Total Billed Charges,68% of Total Billed Charges,197.6,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,130,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,197.6,
SILVER NITRATE STICK,644760,CDM,250,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SINEMET CR 50MG/200MG-TAB,644790,CDM,250,RC,,,Outpatient,200,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,163.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
CARBIDOPA & LEVODOPA 10MG/100M,644800,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CARBIDOPA & LEVODOPA 25MG/100M,644825,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CARBIDOPA/LEVODOPA 25MG/250MG,644826,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SINEMET CR 25MG/100MG-TAB,644850,CDM,250,RC,,,Outpatient,100,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
DOXEPIN HCL 25MG CAP,644900,CDM,250,RC,,,Outpatient,25,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
DOXEPIN 10MG TAB,644905,CDM,250,RC,,,Outpatient,10,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,203.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
SITREX 30/1700MG TAB,644988,CDM,250,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
SINGULAIR 4MG CHEWTAB,644990,CDM,250,RC,,,Outpatient,4,ME,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
SINGULAIR 10MG-TAB,644993,CDM,250,RC,,,Outpatient,10,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
TERAZOL 80MG SUPP,644994,CDM,250,RC,Y7506,HCPCS,Outpatient,80,ME,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,209.76,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,48.64,
SKELAXIN 400MG TABLET,645003,CDM,250,RC,,,Outpatient,400,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
SKELAXIN 800MG TAB,645009,CDM,250,RC,,,Outpatient,800,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
SKIN TEST TUBERCULOSIS,645020,CDM,250,RC,86580,HCPCS,Outpatient,,,17,11.9,,6.92,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,36.35,
SLO-BID 300MG-CAP,645038,CDM,250,RC,,,Outpatient,300,ME,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,13.98,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
THEOPHYLLINE 200MG CAP,645041,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MAG DELAY 64MG-TAB,645073,CDM,250,RC,,,Outpatient,64,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SODIUM BICARBONATE 650MG-TAB,645100,CDM,250,RC,,,Outpatient,650,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
NA BICARBONATE 50M V INJ,645117,CDM,250,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
SODIUM BICARBONATE 4.2%-INJ,645150,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
SODIUM BICARBONATE 8.4% 50ML-I,645200,CDM,250,RC,Y7506,HCPCS,Outpatient,50,ML,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
SODIUM BICARBONATE 8.4% 10CC I,645204,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
SODIUM CHLORIDE 0.9% INJ,645208,CDM,250,RC,J2912,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SODIUM CHLORIDE 0.45% INJECTIO,645210,CDM,250,RC,Y7506,HCPCS,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,54.72,
SODIUM CHLORIDE TABLET 1G,645217,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SOD CHL 23.4% 30ML INJ,645223,CDM,250,RC,,,Outpatient,23430,ML,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
SODIUM PHOSPHATE 45MMOLP/60MEQ,645240,CDM,250,RC,Y7506,HCPCS,Outpatient,,,145,101.5,,,,,,Other,Not Seperately Reimbusable,98.6,68,,78.88,Percent of Total Billed Charges,68% of Total Billed Charges,110.2,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,72.5,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.5,110.2,
SULFACETAMIDE 10% DROPS-EYE,645250,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CARISOPRODOL 350MG-TAB,645800,CDM,250,RC,,,Outpatient,350,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARISOPRODOL & ASPIRIN 200MG/3,645820,CDM,250,RC,,,Outpatient,200,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
SPIRIVA 18MCG (5) INHALE,645890,CDM,250,RC,Y7506,HCPCS,Outpatient,,,102,71.4,,,,,,Other,Not Seperately Reimbusable,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
SORBITOL SL 70% 30ML-LIQ,645894,CDM,250,RC,,,Outpatient,7030,ML,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SPORANOX 100MG-TAB,646075,CDM,250,RC,,,Outpatient,100,ME,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
STADOL NS 10MG/ML NASAL SPRAY,646104,CDM,250,RC,Y7506,HCPCS,Outpatient,10,ME,500,350,,,,,,Other,Not Seperately Reimbusable,340,68,,272,Percent of Total Billed Charges,68% of Total Billed Charges,380,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,250,50,,18,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250,380,
SSKI 30G -LIQ,646148,CDM,250,RC,,,Outpatient,,,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,47.45,65,,37.96,Percent of Total Billed Charges,65% of Total Billed Charges,54.75,75,,43.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,43.8,60,,35.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,55.48,
STRATTERA 10MG CAP,646175,CDM,250,RC,,,Outpatient,10,ME,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,41.6,65,,33.28,Percent of Total Billed Charges,65% of Total Billed Charges,48,75,,38.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,38.4,60,,30.72,Percent of Total Billed Charges,60% of Total Billed Charges,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.06,20.4,,10.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,20,,10.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.8,48.64,
STRATTERA 40MG CAP,646178,CDM,250,RC,,,Outpatient,40,ME,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
STARLIX 120MG TAB,646200,CDM,250,RC,,,Outpatient,120,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
STROMECTOL 3MG TAB,646400,CDM,250,RC,,,Outpatient,3,ME,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,19.5,65,,15.6,Percent of Total Billed Charges,65% of Total Billed Charges,22.5,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,22.8,
SUBOXONE 2/0.5MG TAB,646505,CDM,250,RC,,,Outpatient,205,ME,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,46,Percent of Total Billed Charges,50% of Total Billed Charges,18.2,65,,14.56,Percent of Total Billed Charges,65% of Total Billed Charges,21,75,,16.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,60,,13.44,Percent of Total Billed Charges,60% of Total Billed Charges,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,20.4,,4.57,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,4.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.6,21.28,
SUCRALFATE 1GM TABLET,646510,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PSEUDOEPHEDRINE HCI 30MG-TAB,646550,CDM,250,RC,,,Outpatient,30,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SULAMYD-EYE,646610,CDM,250,RC,Y7506,HCPCS,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,54.72,
SULAR 20MG TAB,646613,CDM,250,RC,,,Outpatient,20,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
SULAR 8.5MG TAB,646614,CDM,250,RC,,,Outpatient,85,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
SULAR 10MG TAB,646615,CDM,250,RC,,,Outpatient,10,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
SULCRAFATE SUSPENSION,646620,CDM,250,RC,Y7506,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
SUFENTA 1ML -INJ,646625,CDM,250,RC,,,Outpatient,1,ML,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.6,65,,22.88,Percent of Total Billed Charges,65% of Total Billed Charges,33,75,,26.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,26.4,60,,21.12,Percent of Total Billed Charges,60% of Total Billed Charges,8.98,20.4,,7.18,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.98,20.4,,7.18,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.8,20,,7.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.8,33.44,
SULFACETAMIDE SODIUM OINTMENT,646640,CDM,250,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
SULFASALAZINE 500MG-TAB,646650,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SUMATRIPTAN 100MG TAB,646700,CDM,250,RC,,,Outpatient,100,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
SUPRANE 10CC,646720,CDM,250,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUPRANE/15 MIN,646730,CDM,250,RC,Y7509,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,57.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SUPRAX 100MG/5ML SUSPENSION,646800,CDM,250,RC,,,Outpatient,100,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
SURFAK 240MG CAP,646850,CDM,250,RC,,,Outpatient,240,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SUS-PHRINE 5MG INJ,646900,CDM,250,RC,J0170,HCPCS,Outpatient,5,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
AMANTADINE HCL 50MG TABLET,647142,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,62.62,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AMANTADINE 100MG CAP,647150,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,57.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 88MCG TAB,647400,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 50MCG TAB,647450,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYMBICORT 80/4.5 INH,647490,CDM,250,RC,,,Outpatient,,,462,323.4,,,,,,Other,Not Seperately Reimbusable,314.16,68,,251.33,Percent of Total Billed Charges,68% of Total Billed Charges,351.12,76,,98.5,Percent of Total Billed Charges,76% of Total Billed Charges,231,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,300.3,65,,240.24,Percent of Total Billed Charges,65% of Total Billed Charges,346.5,75,,277.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.4,20,,73.92,Percent of Total Billed Charges,20% of Total Billed Charges,277.2,60,,221.76,Percent of Total Billed Charges,60% of Total Billed Charges,94.25,20.4,,75.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,94.25,20.4,,75.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,92.4,20,,73.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.4,20,,73.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,92.4,351.12,
SYMBICORT 160/4.5 INH,647495,CDM,250,RC,,,Outpatient,,,686,480.2,,,,,,Other,Not Seperately Reimbusable,466.48,68,,373.18,Percent of Total Billed Charges,68% of Total Billed Charges,521.36,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,343,50,,60.4,Percent of Total Billed Charges,50% of Total Billed Charges,445.9,65,,356.72,Percent of Total Billed Charges,65% of Total Billed Charges,514.5,75,,411.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.2,20,,109.76,Percent of Total Billed Charges,20% of Total Billed Charges,411.6,60,,329.28,Percent of Total Billed Charges,60% of Total Billed Charges,139.94,20.4,,111.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,139.94,20.4,,111.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,137.2,20,,109.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.2,20,,109.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,137.2,521.36,
SYNTHROID 100MCG TAB,647500,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 125MCG TAB,647550,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 150MCG,647570,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 75MCG TAB,647650,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,58,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 112MCG TAB,647660,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNVISC-INJ,647738,CDM,250,RC,Y7506,HCPCS,Outpatient,,,1997,1397.9,,,,,,Other,Not Seperately Reimbusable,1357.96,68,,1086.37,Percent of Total Billed Charges,68% of Total Billed Charges,1517.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,998.5,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,998.5,1517.72,
CIMETIDINE 300MG-TAB,647950,CDM,250,RC,,,Outpatient,300,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
CIMETIDINE 400MG-TAB,648001,CDM,250,RC,,,Outpatient,400,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
TALWIN NX 50MG TAB,648050,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARBAMAZEPINE 100MG-TAB,648647,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TEGRETOL 100MG-TAB,648648,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,47.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARBAMAZEPINE 200MG TAB,648650,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TEGRETOL XR 400MG-TAB,648652,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,60.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARBATROL 100MG TAB,648655,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CARBATROL ER 200MG TAB,648670,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CLOBETASOL PROPIONATE 0.05%-OI,648759,CDM,250,RC,Y7506,HCPCS,Outpatient,,,143,100.1,,,,,,Other,Not Seperately Reimbusable,97.24,68,,77.79,Percent of Total Billed Charges,68% of Total Billed Charges,108.68,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,71.5,50,,36.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.5,108.68,
ATENOLOL 25MG-TAB,648963,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ATENOLOL 50MG-TAB,648972,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ATENOLOL & CHLORTHALIDONE 50MG,648980,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ENLON PLUS 10MG/ML-INJ,648983,CDM,250,RC,Y7506,HCPCS,Outpatient,10,ME,108,75.6,,,,,,Other,Not Seperately Reimbusable,73.44,68,,58.75,Percent of Total Billed Charges,68% of Total Billed Charges,82.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,54,50,,54,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,82.08,
TAMIFLU 12MG/ML 25ML SUSP,648985,CDM,250,RC,,,Outpatient,1225,ME,204,142.8,,,,,,Other,Not Seperately Reimbusable,138.72,68,,110.98,Percent of Total Billed Charges,68% of Total Billed Charges,155.04,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,102,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,132.6,65,,106.08,Percent of Total Billed Charges,65% of Total Billed Charges,153,75,,122.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.8,20,,32.64,Percent of Total Billed Charges,20% of Total Billed Charges,122.4,60,,97.92,Percent of Total Billed Charges,60% of Total Billed Charges,41.62,20.4,,33.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,41.62,20.4,,33.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,40.8,20,,32.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.8,20,,32.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.8,155.04,
TAMIFLU 45MG CAP,648986,CDM,250,RC,,,Outpatient,45,ME,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,53.95,65,,43.16,Percent of Total Billed Charges,65% of Total Billed Charges,62.25,75,,49.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.6,20,,13.28,Percent of Total Billed Charges,20% of Total Billed Charges,49.8,60,,39.84,Percent of Total Billed Charges,60% of Total Billed Charges,16.93,20.4,,13.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.93,20.4,,13.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,16.6,20,,13.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.6,20,,13.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.6,63.08,
TAMIFLU 75MG CAP,648987,CDM,250,RC,,,Outpatient,75,ME,82,57.4,,,,,,Other,Not Seperately Reimbusable,55.76,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,62.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,41,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,53.3,65,,42.64,Percent of Total Billed Charges,65% of Total Billed Charges,61.5,75,,49.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,49.2,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,16.73,20.4,,13.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.73,20.4,,13.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.4,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.4,62.32,
TERAZOL 3 0.8% CREAM,648991,CDM,250,RC,Y7506,HCPCS,Outpatient,,,242,169.4,,,,,,Other,Not Seperately Reimbusable,164.56,68,,131.65,Percent of Total Billed Charges,68% of Total Billed Charges,183.92,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,121,50,,54,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121,183.92,
TERAZOL 7 0.4% CREAM,648992,CDM,250,RC,Y7506,HCPCS,Outpatient,,,190,133,,,,,,Other,Not Seperately Reimbusable,129.2,68,,103.36,Percent of Total Billed Charges,68% of Total Billed Charges,144.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,95,50,,54,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95,144.4,
TEQUIN 400MG TABLET,649000,CDM,250,RC,,,Outpatient,400,ME,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,40.95,65,,32.76,Percent of Total Billed Charges,65% of Total Billed Charges,47.25,75,,37.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,37.8,60,,30.24,Percent of Total Billed Charges,60% of Total Billed Charges,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.85,20.4,,10.28,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,20,,10.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.6,47.88,
TEQUIN 400MG/200ML PREMIX-INJ,649001,CDM,250,RC,Y7506,HCPCS,Outpatient,,,211,147.7,,,,,,Other,Not Seperately Reimbusable,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,105.5,50,,54,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,160.36,
TEQUIN 400MG VIAL-INJ,649002,CDM,250,RC,J1590,HCPCS,Outpatient,400,ME,211,147.7,,,,,,Other,Not Seperately Reimbusable,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,105.5,50,,59.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,160.36,
TEQUIN PREMIXED 200MG/100ML IN,649003,CDM,250,RC,J1590,HCPCS,Outpatient,200,ME,113,79.1,,,,,,Other,Not Seperately Reimbusable,76.84,68,,61.47,Percent of Total Billed Charges,68% of Total Billed Charges,85.88,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,56.5,50,,83.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.5,85.88,
BENZONATATE 100MG-CAP,649250,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TERRAMYCIN 50MG/ML INJ,649340,CDM,250,RC,J2460,HCPCS,Outpatient,50,ME,62,43.4,,0.89,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,103.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
TETANUS & DIPTHERIA TOX PED IN,649354,CDM,250,RC,90715,HCPCS,Outpatient,,,115,80.5,,38.31,100,,,fee schedule,100% Aetna Market fee schedule,78.2,68,,62.56,Percent of Total Billed Charges,68% of Total Billed Charges,87.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,57.5,50,,83.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.5,87.4,
TETRACAINE DROPPERETTES 0.5%-E,649435,CDM,250,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,83.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
TETRACYCLINE 250MG-CAP,649450,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TEVETEN 600MG TABLET,649480,CDM,250,RC,,,Outpatient,600,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
THEO-24 300MG-CAP,649625,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
THEOPHYLLINE 100MG-TAB,649650,CDM,250,RC,,,Outpatient,100,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
THEOPHYLLINE ER 200MG-TAB,649675,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THEOPHYLLINE ER 300MG-TAB,649700,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THEO-24 400MG-TAB,649800,CDM,250,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
THERAGESIC CREAM,649850,CDM,250,RC,Y7506,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,10.88,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
THEOPHYLLINE ELIX-80MG/15ML,649880,CDM,250,RC,,,Outpatient,8015,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
THERAPEUTIC MULTIVITAMIN-TAB,649900,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THERAGRAN HEMATINIC -TAB,649950,CDM,250,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
THERAPEUTIC M TAB,650000,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THERAVTE SYRUP,650038,CDM,250,RC,,,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,65,,22.36,Percent of Total Billed Charges,65% of Total Billed Charges,32.25,75,,25.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,32.68,
THERMAZENE 1% CREAM  400GM,650040,CDM,250,RC,Y7506,HCPCS,Outpatient,,,260,182,,,,,,Other,Not Seperately Reimbusable,176.8,68,,141.44,Percent of Total Billed Charges,68% of Total Billed Charges,197.6,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,130,50,,228.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,197.6,
PERMETHRIN 5% CREAM,650050,CDM,250,RC,Y7506,HCPCS,Outpatient,,,354,247.8,,,,,,Other,Not Seperately Reimbusable,240.72,68,,192.58,Percent of Total Billed Charges,68% of Total Billed Charges,269.04,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,177,50,,228.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177,269.04,
PERMETHRIN 1% LOTION KIT,650075,CDM,250,RC,Y7506,HCPCS,Outpatient,,,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,228.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
VITAMIN B-1 100MG-TAB,650100,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THYROID 65MG TABLET,650160,CDM,250,RC,,,Outpatient,65,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHLORPROMAZINE 100MG TAB,650250,CDM,250,RC,,,Outpatient,100,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
CHLORPROMAZINE HCL 25MG TAB,650300,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
CHLORTHALIDONE 25MG TAB,650400,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TICLID 250MG-TAB,650872,CDM,250,RC,,,Outpatient,250,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
TIGAN 200MG-TAB,651002,CDM,250,RC,,,Outpatient,200,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
TIGAN 100MG SUPP,651050,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
TIGAN 200MG SUPP,651100,CDM,250,RC,Y7506,HCPCS,Outpatient,200,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
TIMOLOL MALEATE 0.5% DROPS-EYE,651140,CDM,250,RC,Y7506,HCPCS,Outpatient,,,172,120.4,,,,,,Other,Not Seperately Reimbusable,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86,130.72,
TIMOPTIC XE 0.5% 2.5ML-EYE,651150,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
TIMOPTIC 0.5% OPTH-EYE,651200,CDM,250,RC,Y7506,HCPCS,Outpatient,,,172,120.4,,,,,,Other,Not Seperately Reimbusable,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86,130.72,
TIMOPTIC XE 0.5% 5ML-EYE,651203,CDM,250,RC,Y7506,HCPCS,Outpatient,55,ML,183,128.1,,,,,,Other,Not Seperately Reimbusable,124.44,68,,99.55,Percent of Total Billed Charges,68% of Total Billed Charges,139.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,91.5,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.5,139.08,
TOBRADEX 2.5ML-EYE,651311,CDM,250,RC,Y7506,HCPCS,Outpatient,25,ML,330,231,,,,,,Other,Not Seperately Reimbusable,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,165,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,250.8,
TOBRADEX EYE OINT 3.5GM,651315,CDM,250,RC,Y7506,HCPCS,Outpatient,,,506,354.2,,,,,,Other,Not Seperately Reimbusable,344.08,68,,275.26,Percent of Total Billed Charges,68% of Total Billed Charges,384.56,76,,45.15,Percent of Total Billed Charges,76% of Total Billed Charges,253,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253,384.56,
TOBREX 0.3%-EYE,651327,CDM,250,RC,Y7506,HCPCS,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,27.2,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
IMIPRAMINE HCL 10MG-TAB,651350,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,48.96,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IMIPRAMINE 50MG TAB,651375,CDM,250,RC,,,Outpatient,50,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,308.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
TOFRANIL 25MG TAB,651400,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,34.27,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
COMBIGAN 0.2/0.5% EYE DROPS,651650,CDM,250,RC,,,Outpatient,,,386,270.2,,,,,,Other,Not Seperately Reimbusable,262.48,68,,209.98,Percent of Total Billed Charges,68% of Total Billed Charges,293.36,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,193,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,250.9,65,,200.72,Percent of Total Billed Charges,65% of Total Billed Charges,289.5,75,,231.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,231.6,60,,185.28,Percent of Total Billed Charges,60% of Total Billed Charges,78.74,20.4,,62.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.74,20.4,,62.99,Percent of Total Billed Charges,20.4% of Total Billed Charges,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.2,20,,61.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,77.2,293.36,
TOLNAFTATE 1% OINT,651665,CDM,250,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
TOPAMAX 25MG-TAB,651670,CDM,250,RC,,,Outpatient,25,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
TOPAMAX 100MG-TAB,651672,CDM,250,RC,,,Outpatient,100,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,42.43,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
TOPICORT 15GR CREAM,651675,CDM,250,RC,Y7506,HCPCS,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,59.84,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
TOPROL 25MG TABLET,651680,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,31.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TOPROL XL 50MG-TAB,651681,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,45.15,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TOPROL XL 100MG TABLET,651682,CDM,250,RC,,,Outpatient,100,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
TORADOL 10MG-TAB,651689,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,39.17,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
INTRALIPID 20% INJ,651691,CDM,250,RC,Y7506,HCPCS,Outpatient,,,308,215.6,,,,,,Other,Not Seperately Reimbusable,209.44,68,,167.55,Percent of Total Billed Charges,68% of Total Billed Charges,234.08,76,,53.86,Percent of Total Billed Charges,76% of Total Billed Charges,154,50,,122.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154,234.08,
GLYCOPYRROLATE 2MG TAB,651696,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.32,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
TPN SOLUTION,651750,CDM,250,RC,Y7507,HCPCS,Outpatient,,,1065,745.5,,,,,,Other,Not Seperately Reimbusable,724.2,68,,579.36,Percent of Total Billed Charges,68% of Total Billed Charges,809.4,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,532.5,50,,122.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,532.5,809.4,
TRILEPTAL 300MG TAB,651790,CDM,250,RC,,,Outpatient,300,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
TRACE ELEMENTS-INJ,651860,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
TRACLEER 125MG TAB,651865,CDM,250,RC,,,Outpatient,125,ME,398,278.6,,,,,,Other,Not Seperately Reimbusable,270.64,68,,216.51,Percent of Total Billed Charges,68% of Total Billed Charges,302.48,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,199,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,258.7,65,,206.96,Percent of Total Billed Charges,65% of Total Billed Charges,298.5,75,,238.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.6,20,,63.68,Percent of Total Billed Charges,20% of Total Billed Charges,238.8,60,,191.04,Percent of Total Billed Charges,60% of Total Billed Charges,81.19,20.4,,64.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.19,20.4,,64.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,79.6,20,,63.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.6,20,,63.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.6,302.48,
TRADJENTA 5MG TAB,651869,CDM,250,RC,,,Outpatient,5,ME,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,43.52,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36.48,
NIMBEX 10ML -INJ,651870,CDM,250,RC,,,Outpatient,10,ML,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,19.58,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,45.5,65,,36.4,Percent of Total Billed Charges,65% of Total Billed Charges,52.5,75,,42,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,20,,11.2,Percent of Total Billed Charges,20% of Total Billed Charges,42,60,,33.6,Percent of Total Billed Charges,60% of Total Billed Charges,14.28,20.4,,11.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.28,20.4,,11.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,14,20,,11.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,20,,11.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,53.2,
TRIMOX 125MG/5ML SUSPENSION,651872,CDM,250,RC,,,Outpatient,1255,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,16.32,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
LABETALOL 100MG-TAB,651873,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,19.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TRIMOX 250MG/5ML SUSPENSION,651874,CDM,250,RC,,,Outpatient,250,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
LABETALOL 100MG/20ML MDV INJ,651875,CDM,250,RC,,,Outpatient,100,ME,34,23.8,,,,,,Other,Not Seperately Reimbusable,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.1,65,,17.68,Percent of Total Billed Charges,65% of Total Billed Charges,25.5,75,,20.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,20.4,60,,16.32,Percent of Total Billed Charges,60% of Total Billed Charges,6.94,20.4,,5.55,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.94,20.4,,5.55,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,20,,5.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.8,25.84,
NITROGLYCERIN 0.2MG/HR  PATCH,651876,CDM,250,RC,Y7506,HCPCS,Outpatient,2,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,181.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
NITROGLYCERIN 0.4MG/HR-PATCH,651877,CDM,250,RC,Y7506,HCPCS,Outpatient,4,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,21.22,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,62.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
TRANXENE 3.75MG CAP,651900,CDM,250,RC,,,Outpatient,375,ME,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
PENTOXIL 400MG-TAB,651933,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,45.15,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,94.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PERPHENAZINE/AMITRIPTYLIN 2MG/,652050,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,19.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PERPHENAZINE/AMITRITYLLIN 2MG/,652100,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,45.15,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,103.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TRUSOPT 2% DROPS-EYE,652491,CDM,250,RC,Y7506,HCPCS,Outpatient,,,162,113.4,,,,,,Other,Not Seperately Reimbusable,110.16,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,123.12,76,,16.32,Percent of Total Billed Charges,76% of Total Billed Charges,81,50,,119.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81,123.12,
TUBERCULIN PURIFIED TUBE 5U.S.,652500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,131,91.7,,,,,,Other,Not Seperately Reimbusable,89.08,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,99.56,76,,19.58,Percent of Total Billed Charges,76% of Total Billed Charges,65.5,50,,130,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.5,99.56,
TUBOCURARINE 3MG/ML,652550,CDM,250,RC,,,Outpatient,3,ME,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,17.41,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,214.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
TUCKS-TOPICAL,652572,CDM,250,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,40.26,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
TUDORZA 400MCG INH,652600,CDM,250,RC,,,Outpatient,,,410,287,,,,,,Other,Not Seperately Reimbusable,278.8,68,,223.04,Percent of Total Billed Charges,68% of Total Billed Charges,311.6,76,,24.48,Percent of Total Billed Charges,76% of Total Billed Charges,205,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,266.5,65,,213.2,Percent of Total Billed Charges,65% of Total Billed Charges,307.5,75,,246,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,20,,65.6,Percent of Total Billed Charges,20% of Total Billed Charges,246,60,,196.8,Percent of Total Billed Charges,60% of Total Billed Charges,83.64,20.4,,66.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,83.64,20.4,,66.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,82,20,,65.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,20,,65.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82,311.6,
TUMS 500MG CHEW TAB,652606,CDM,250,RC,,,Outpatient,500,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,27.2,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
TUSSI-ORGANIDIN S NR 100MG/10M,652750,CDM,250,RC,,,Outpatient,100,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
TUSSIONEX SUSP 5ML,652780,CDM,250,RC,,,Outpatient,5,ML,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
TYLENOL 325MG TAB,652900,CDM,250,RC,,,Outpatient,325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,26.66,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
TYLENOL 15ML DROPS,652950,CDM,250,RC,,,Outpatient,15,ML,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,97.92,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
ACETAMINOPHEN 325MG UD SUS,653000,CDM,250,RC,,,Outpatient,325,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,8.7,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,348.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
TYLENOL 160MG/5ML BOTTLE,653107,CDM,250,RC,,,Outpatient,1605,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,83.23,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
TYLENOL #3-TAB,653150,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,84.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DULOXETINE 20MG DR CAP,653151,CDM,250,RC,,,Outpatient,20,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,27.2,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ACETAMINOPHEN/CODEINE,653200,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,62.56,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,513.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ACETAMINOPHEN/CODEINE 15ML-LIQ,653300,CDM,250,RC,,,Outpatient,15,ML,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
TYLENOL ES 500MG CAP,653350,CDM,250,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,128.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ACETAMINOPHEN 120MG-SUPP,653375,CDM,250,RC,Y7506,HCPCS,Outpatient,120,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,592,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FEVERALL 325MG-SUPP,653400,CDM,250,RC,Y7506,HCPCS,Outpatient,325,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,189.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,499.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ACETAMINOPHEN SUPP 650MG,653450,CDM,250,RC,Y7506,HCPCS,Outpatient,650,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TYMPAGESIC OTIC 0.25%-5%-EAR,653500,CDM,250,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,110,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
ULTRACET 37.5/325MG TAB,653560,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ULTRAM 50MG-TAB,653583,CDM,250,RC,,,Outpatient,50,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,135.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
UNIPHYL 400MG TABLET,653600,CDM,250,RC,,,Outpatient,400,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
UNIVASC 7.5MG-TAB,653620,CDM,250,RC,,,Outpatient,75,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
BETHANE CHOL 50MG TAB,653630,CDM,250,RC,,,Outpatient,50,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
DIAZEPAM 2MG TABLET,654050,CDM,250,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,147.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
DIAZEPAM 5MG-TAB,654100,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,87.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,228.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
UROGESIC BLUE,654150,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
UROXATRAL ER TAB 10MG,654195,CDM,250,RC,,,Outpatient,10,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
VALPROATE 500MG INJ,654205,CDM,250,RC,,,Outpatient,500,ME,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.55,65,,45.24,Percent of Total Billed Charges,65% of Total Billed Charges,65.25,75,,52.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,52.2,60,,41.76,Percent of Total Billed Charges,60% of Total Billed Charges,17.75,20.4,,14.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.75,20.4,,14.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.4,20,,13.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,17.4,66.12,
VALPROIC ACID 250MG -CAP,654210,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SODIUM CHLORIDE 0.9% PAB 100ML,654211,CDM,250,RC,Y7506,HCPCS,Outpatient,100,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,171.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
SODIUM CHLORIDE 0.9% 50ML INJE,654213,CDM,250,RC,Y7506,HCPCS,Outpatient,50,ML,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,91.81,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,171.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
VALTREX 500MG-CAP,654232,CDM,250,RC,,,Outpatient,500,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,105.18,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
URSODIOL 300MG CAPSULE,654240,CDM,250,RC,,,Outpatient,300,ME,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
VANCERIL 42MCG INHALER,654250,CDM,250,RC,Y7506,HCPCS,Outpatient,,,256,179.2,,,,,,Other,Not Seperately Reimbusable,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,194.56,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,128,50,,110,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128,194.56,
VANCOCIN HCL 125MG-CAP,654260,CDM,250,RC,,,Outpatient,125,ME,125,87.5,,,,,,Other,Not Seperately Reimbusable,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,81.25,65,,65,Percent of Total Billed Charges,65% of Total Billed Charges,93.75,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,75,60,,60,Percent of Total Billed Charges,60% of Total Billed Charges,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.5,20.4,,20.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,20,,20,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,95,
VANCOMYCIN 1.5MG SOLUTION,654262,CDM,250,RC,Y7506,HCPCS,Outpatient,15,ME,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,192.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
VANCOCIN 250MG CAP,654265,CDM,250,RC,,,Outpatient,250,ME,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,65,,55.64,Percent of Total Billed Charges,65% of Total Billed Charges,80.25,75,,64.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,64.2,60,,51.36,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,20.4,,17.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.83,20.4,,17.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.4,81.32,
VANCOMYCIN SUSP 50MG/ML 300ML,654266,CDM,250,RC,,,Outpatient,,,432,302.4,,,,,,Other,Not Seperately Reimbusable,293.76,68,,235.01,Percent of Total Billed Charges,68% of Total Billed Charges,328.32,76,,529.57,Percent of Total Billed Charges,76% of Total Billed Charges,216,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,280.8,65,,224.64,Percent of Total Billed Charges,65% of Total Billed Charges,324,75,,259.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.4,20,,69.12,Percent of Total Billed Charges,20% of Total Billed Charges,259.2,60,,207.36,Percent of Total Billed Charges,60% of Total Billed Charges,88.13,20.4,,70.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88.13,20.4,,70.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,86.4,20,,69.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.4,20,,69.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.4,328.32,
VANTIN 100MG/5ML-LIQ,654269,CDM,250,RC,,,Outpatient,100,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,202.46,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
BRIMONIDINE 0.2% OPH DROPS,654273,CDM,250,RC,,,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,46.82,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,75,,39,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,39,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13,49.4,
VASOPRESSIN INJ 20U/ML,654550,CDM,250,RC,,,Outpatient,20,ML,730,511,,,,,,Other,Not Seperately Reimbusable,496.4,68,,397.12,Percent of Total Billed Charges,68% of Total Billed Charges,554.8,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,365,50,,385.2,Percent of Total Billed Charges,50% of Total Billed Charges,474.5,65,,379.6,Percent of Total Billed Charges,65% of Total Billed Charges,547.5,75,,438,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146,20,,116.8,Percent of Total Billed Charges,20% of Total Billed Charges,438,60,,350.4,Percent of Total Billed Charges,60% of Total Billed Charges,148.92,20.4,,119.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,148.92,20.4,,119.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,146,20,,116.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146,20,,116.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146,554.8,
VASOTEC 5MG-TAB,654553,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,167.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
VASOTEC 10MG-TAB,654555,CDM,250,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ENALPRIL MALEATE 20MG-TAB,654556,CDM,250,RC,,,Outpatient,20,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
VASOTEC IV 2.5MG-INJ,654557,CDM,250,RC,,,Outpatient,25,ME,164,114.8,,,,,,Other,Not Seperately Reimbusable,111.52,68,,89.22,Percent of Total Billed Charges,68% of Total Billed Charges,124.64,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,82,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,106.6,65,,85.28,Percent of Total Billed Charges,65% of Total Billed Charges,123,75,,98.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.8,20,,26.24,Percent of Total Billed Charges,20% of Total Billed Charges,98.4,60,,78.72,Percent of Total Billed Charges,60% of Total Billed Charges,33.46,20.4,,26.77,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,33.46,20.4,,26.77,Percent of Total Billed Charges,20.4% of Total Billed Charges,32.8,20,,26.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.8,20,,26.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.8,124.64,
VEETIDS 250MG/5ML SUSPENSION-L,654577,CDM,250,RC,,,Outpatient,250,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
VESICARE 5MG TAB,654750,CDM,250,RC,,,Outpatient,5,ME,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,14.04,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,16.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,12.96,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,4.41,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,4.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
VENTOLIN INHALER,654763,CDM,250,RC,Y7506,HCPCS,Outpatient,,,71,49.7,,,,,,Other,Not Seperately Reimbusable,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,752.7,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,300.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.5,53.96,
VERSED SYRUP 2MG/ML-LIQ,654824,CDM,250,RC,,,Outpatient,2,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,418,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
VESANOID 10MG CAP,654850,CDM,250,RC,,,Outpatient,10,ME,104,72.8,,,,,,Other,Not Seperately Reimbusable,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,79.04,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.6,65,,54.08,Percent of Total Billed Charges,65% of Total Billed Charges,78,75,,62.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,62.4,60,,49.92,Percent of Total Billed Charges,60% of Total Billed Charges,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.8,79.04,
DOXYCYCLINE HYCLATE 100MG-TAB,655000,CDM,250,RC,,,Outpatient,100,ME,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,167.81,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
DOXYLAMINE SUCCINATE 25MG TAB,655050,CDM,250,RC,,,Outpatient,25,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
VICOPROFEN 7.5MG/200MG-TAB,655137,CDM,250,RC,,,Outpatient,200,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
VIGAMOX 0.5% DROPS,655190,CDM,250,RC,,,Outpatient,,,394,275.8,,,,,,Other,Not Seperately Reimbusable,267.92,68,,214.34,Percent of Total Billed Charges,68% of Total Billed Charges,299.44,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,197,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,256.1,65,,204.88,Percent of Total Billed Charges,65% of Total Billed Charges,295.5,75,,236.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,236.4,60,,189.12,Percent of Total Billed Charges,60% of Total Billed Charges,80.38,20.4,,64.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,80.38,20.4,,64.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.8,20,,63.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,78.8,299.44,
VIMPAT 50MG TAB,655200,CDM,250,RC,,,Outpatient,50,ME,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,58.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.15,65,,26.52,Percent of Total Billed Charges,65% of Total Billed Charges,38.25,75,,30.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,30.6,60,,24.48,Percent of Total Billed Charges,60% of Total Billed Charges,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,20.4,,8.32,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.2,20,,8.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,38.76,
VIOXX 12.5MG TAB,655205,CDM,250,RC,,,Outpatient,125,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,220.1,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,92.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
VIOXX 25MG TAB,655210,CDM,250,RC,,,Outpatient,25,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,451.14,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
VIOXX 50MG TAB,655212,CDM,250,RC,,,Outpatient,50,ME,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,217.66,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
HYDROXYZINE PAMOATE 25MG-CAP,655250,CDM,250,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,182.78,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
VISTARIL 25MG/5ML LIQ,655550,CDM,250,RC,,,Outpatient,255,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,260.22,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,418,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
VITAMIN B-12 TAB,655671,CDM,250,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,195.78,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,818.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
VILAZODONE 10MG TAB,655672,CDM,250,RC,,,Outpatient,10,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,899.84,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
VITAMIN D 1000IU TAB,655673,CDM,250,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,759.39,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,115.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
VITAMIN D 400IU TAB,655674,CDM,250,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
"VITAMIN D 50,000U CAP",655675,CDM,250,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,149.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
VITAMIN E 400IU-CAP,655677,CDM,250,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,224.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
VOLTAREN XR 100MG TAB,655835,CDM,250,RC,,,Outpatient,100,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
VYTORIN TAB 10/20MG,655850,CDM,250,RC,,,Outpatient,1020,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,31.55,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
VYTORIN TAB 10/40MG,655855,CDM,250,RC,,,Outpatient,1040,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,65.28,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
WELLBUTRIN SR 100MG TAB,656019,CDM,250,RC,,,Outpatient,100,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,223.74,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
WELLBUTRIN SR 150MG-TAB,656021,CDM,250,RC,,,Outpatient,150,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,216.51,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
WELLBUTRIN 75MG-TAB,656024,CDM,250,RC,,,Outpatient,75,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,311.17,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
WELLBUTRIN 100MG-TAB,656026,CDM,250,RC,,,Outpatient,100,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,338.91,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
WELLBUTRIN XL 150MG TAB,656028,CDM,250,RC,,,Outpatient,150,ME,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,262.21,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.7,65,,40.56,Percent of Total Billed Charges,65% of Total Billed Charges,58.5,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,46.8,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.6,59.28,
WITCH HAZEL 16OZ -SOLUTION,656100,CDM,250,RC,Y7506,HCPCS,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,239.9,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
GENT/CLEOMYCIN/POLYMOXIN 250/2,656102,CDM,250,RC,Y7506,HCPCS,Outpatient,,,773,541.1,,,,,,Other,Not Seperately Reimbusable,525.64,68,,420.51,Percent of Total Billed Charges,68% of Total Billed Charges,587.48,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,386.5,50,,309.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.5,587.48,
WITCH HAZEL PADS,656105,CDM,250,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
XARELTO 15MG TAB,656200,CDM,250,RC,,,Outpatient,15,ME,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,48.75,65,,39,Percent of Total Billed Charges,65% of Total Billed Charges,56.25,75,,45,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,45,60,,36,Percent of Total Billed Charges,60% of Total Billed Charges,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.3,20.4,,12.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,20,,12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15,57,
ALPRAZOLAM 0.5MG-TAB,656311,CDM,250,RC,,,Outpatient,5,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
XENADERM 30GM OINT,656314,CDM,250,RC,Y7506,HCPCS,Outpatient,,,301,210.7,,,,,,Other,Not Seperately Reimbusable,204.68,68,,163.74,Percent of Total Billed Charges,68% of Total Billed Charges,228.76,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,150.5,50,,120.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.5,228.76,
XYLOCAINE 1% 10MG-INJ,656400,CDM,250,RC,,,Outpatient,110,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
XYLOCAINE 0.5% 50 ML-INJ,656403,CDM,250,RC,,,Outpatient,550,ML,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
LIDOCAINE 5% OINTMENT,656405,CDM,250,RC,Y7506,HCPCS,Outpatient,,,660,462,,,,,,Other,Not Seperately Reimbusable,448.8,68,,359.04,Percent of Total Billed Charges,68% of Total Billed Charges,501.6,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,330,50,,264,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,501.6,
XYLOCAINE-MPF 0.5% INJECTION,656430,CDM,250,RC,,,Outpatient,,,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,68,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.4,65,,39.52,Percent of Total Billed Charges,65% of Total Billed Charges,57,75,,45.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.2,20,,12.16,Percent of Total Billed Charges,20% of Total Billed Charges,45.6,60,,36.48,Percent of Total Billed Charges,60% of Total Billed Charges,15.5,20.4,,12.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.5,20.4,,12.4,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.2,20,,12.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.2,20,,12.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.2,57.76,
XYLOCAINE-MPF 1% INJ,656431,CDM,250,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,202.37,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
XYLOCAINE-MPF 2% 20MG INJECTIO,656432,CDM,250,RC,J2001,HCPCS,Outpatient,220,ME,14,9.8,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
XYLOCAINE C EPI 1% 10MG-INJ,656453,CDM,250,RC,,,Outpatient,110,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,585.5,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
LIDOCAINE GEL 5%,656550,CDM,250,RC,Y7506,HCPCS,Outpatient,,,124,86.8,,,,,,Other,Not Seperately Reimbusable,84.32,68,,67.46,Percent of Total Billed Charges,68% of Total Billed Charges,94.24,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,62,50,,49.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,94.24,
XYLOCAINE 2%-INJ,656600,CDM,250,RC,J2001,HCPCS,Outpatient,,,107,74.9,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,585.5,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
LIDOCAINE VISCOUS 2% SOLUTION,656700,CDM,250,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
XYLOCAINE/PT OINT,656750,CDM,250,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
YOHIMBINE HCL 5.4MG-TAB,656768,CDM,250,RC,,,Outpatient,54,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
ZANAFLEX 4MG TAB,656800,CDM,250,RC,,,Outpatient,4,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
RANITIDINE 150MG-TAB,656810,CDM,250,RC,,,Outpatient,150,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ZANTAC 15MG/ML LIQ,656813,CDM,250,RC,,,Outpatient,15,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZANTAC 50MG/50ML-INJ,656815,CDM,250,RC,J2780,HCPCS,Outpatient,5050,ME,38,26.6,,6.26,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
ZAROXOLYN 2.5MG TAB,656848,CDM,250,RC,,,Outpatient,25,ME,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
ZAROXOLYN 10MG,656849,CDM,250,RC,,,Outpatient,10,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ZAROXOLYN 5MG,656850,CDM,250,RC,,,Outpatient,5,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
ZELNORM 2MG TAB,656851,CDM,250,RC,,,Outpatient,2,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
ZEBETA 5MG TABLET,656852,CDM,250,RC,,,Outpatient,5,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ZEMURON 10MG/ML-INJ,656853,CDM,250,RC,,,Outpatient,10,ME,99,69.3,,,,,,Other,Not Seperately Reimbusable,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,75.24,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,64.35,65,,51.48,Percent of Total Billed Charges,65% of Total Billed Charges,74.25,75,,59.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,59.4,60,,47.52,Percent of Total Billed Charges,60% of Total Billed Charges,20.2,20.4,,16.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.2,20.4,,16.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.8,20,,15.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.8,75.24,
ZERIT 20MG TAB,656854,CDM,250,RC,,,Outpatient,20,ME,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
ZESTRIL 5MG TABLET,656855,CDM,250,RC,,,Outpatient,5,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
ZETIG 10MG TAB,656860,CDM,250,RC,,,Outpatient,10,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
ZIAC 2.5MG-TAB,656862,CDM,250,RC,,,Outpatient,25,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ZAIC 5MG,656863,CDM,250,RC,,,Outpatient,5,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ZIAC 5MG TAB,656865,CDM,250,RC,,,Outpatient,5,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
ZIAGEN 300MG TAB,656870,CDM,250,RC,,,Outpatient,300,ME,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.9,65,,23.92,Percent of Total Billed Charges,65% of Total Billed Charges,34.5,75,,27.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,27.6,60,,22.08,Percent of Total Billed Charges,60% of Total Billed Charges,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.38,20.4,,7.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.2,20,,7.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.2,34.96,
ZIDOVUDINE SYRUP 240ML,656871,CDM,250,RC,,,Outpatient,240,ML,234,163.8,,,,,,Other,Not Seperately Reimbusable,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,152.1,65,,121.68,Percent of Total Billed Charges,65% of Total Billed Charges,175.5,75,,140.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.8,20,,37.44,Percent of Total Billed Charges,20% of Total Billed Charges,140.4,60,,112.32,Percent of Total Billed Charges,60% of Total Billed Charges,47.74,20.4,,38.19,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.74,20.4,,38.19,Percent of Total Billed Charges,20.4% of Total Billed Charges,46.8,20,,37.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.8,20,,37.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.8,177.84,
CEFUROXIME AXOTIL 500MG TAB,656875,CDM,250,RC,,,Outpatient,500,ME,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,32.5,65,,26,Percent of Total Billed Charges,65% of Total Billed Charges,37.5,75,,30,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,30,60,,24,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,20.4,,8.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,20.4,,8.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,38,
ZINC OXIDE 30 GRAMS OINT,656900,CDM,250,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ZINC SULFATE 220MG CAP,656950,CDM,250,RC,,,Outpatient,220,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZIOX OINTMENT,656955,CDM,250,RC,Y7506,HCPCS,Outpatient,,,426,298.2,,,,,,Other,Not Seperately Reimbusable,289.68,68,,231.74,Percent of Total Billed Charges,68% of Total Billed Charges,323.76,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,213,50,,170.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213,323.76,
ZITHROMAX 100MG/5ML POWDER-SUS,656966,CDM,250,RC,,,Outpatient,100,ME,186,130.2,,,,,,Other,Not Seperately Reimbusable,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,141.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,120.9,65,,96.72,Percent of Total Billed Charges,65% of Total Billed Charges,139.5,75,,111.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.2,20,,29.76,Percent of Total Billed Charges,20% of Total Billed Charges,111.6,60,,89.28,Percent of Total Billed Charges,60% of Total Billed Charges,37.94,20.4,,30.35,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.94,20.4,,30.35,Percent of Total Billed Charges,20.4% of Total Billed Charges,37.2,20,,29.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.2,20,,29.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.2,141.36,
ZITHROMAX 200MG/5ML 30ML SUSP,656968,CDM,250,RC,,,Outpatient,200,ME,189,132.3,,,,,,Other,Not Seperately Reimbusable,128.52,68,,102.82,Percent of Total Billed Charges,68% of Total Billed Charges,143.64,76,,114.91,Percent of Total Billed Charges,76% of Total Billed Charges,94.5,50,,75.6,Percent of Total Billed Charges,50% of Total Billed Charges,122.85,65,,98.28,Percent of Total Billed Charges,65% of Total Billed Charges,141.75,75,,113.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.8,20,,30.24,Percent of Total Billed Charges,20% of Total Billed Charges,113.4,60,,90.72,Percent of Total Billed Charges,60% of Total Billed Charges,38.56,20.4,,30.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.56,20.4,,30.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,37.8,20,,30.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.8,20,,30.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,37.8,143.64,
ZITHROMAX 250MG-TAB,656970,CDM,250,RC,,,Outpatient,250,ME,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,39,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,31.2,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.61,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.4,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.4,39.52,
ZITHROMAX 500MG IV INJ,656971,CDM,250,RC,,,Outpatient,500,ME,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
ZOCOR 10MG-TAB,656974,CDM,250,RC,,,Outpatient,10,ME,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,12.35,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,11.4,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.88,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.8,14.44,
ZOLOFT 25MG TAB,656975,CDM,250,RC,,,Outpatient,25,ME,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
ZOFRAN 4MG TAB,656977,CDM,250,RC,,,Outpatient,4,ME,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,89.05,65,,71.24,Percent of Total Billed Charges,65% of Total Billed Charges,102.75,75,,82.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,82.2,60,,65.76,Percent of Total Billed Charges,60% of Total Billed Charges,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.95,20.4,,22.36,Percent of Total Billed Charges,20.4% of Total Billed Charges,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.4,20,,21.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.4,104.12,
ZOCOR 40MG TABLET,656979,CDM,250,RC,,,Outpatient,40,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
ACYCLOVIR 200MG-CAP,656980,CDM,250,RC,,,Outpatient,200,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZONEGRAN 100MG TABLET,656981,CDM,250,RC,,,Outpatient,100,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
ZOVIRAX 200MG/5ML SUSP,656983,CDM,250,RC,,,Outpatient,200,ME,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
ZOCOR 80MG TAB,656984,CDM,250,RC,,,Outpatient,80,ME,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.8,65,,16.64,Percent of Total Billed Charges,65% of Total Billed Charges,24,75,,19.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,19.2,60,,15.36,Percent of Total Billed Charges,60% of Total Billed Charges,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.53,20.4,,5.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,20,,5.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.4,24.32,
ZOVIRAX 5% OINT 15GM,656985,CDM,250,RC,Y7506,HCPCS,Outpatient,,,420,294,,,,,,Other,Not Seperately Reimbusable,285.6,68,,228.48,Percent of Total Billed Charges,68% of Total Billed Charges,319.2,76,,255.36,Percent of Total Billed Charges,76% of Total Billed Charges,210,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,319.2,
ZOMIG 5MG-TAB,656986,CDM,250,RC,,,Outpatient,5,ME,97,67.9,,,,,,Other,Not Seperately Reimbusable,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,73.72,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,48.5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.05,65,,50.44,Percent of Total Billed Charges,65% of Total Billed Charges,72.75,75,,58.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,58.2,60,,46.56,Percent of Total Billed Charges,60% of Total Billed Charges,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,73.72,
ZOSYN 2.25 GRAM-INJ,656987,CDM,250,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
ZOSYN 3.375 GRAM-INJ,656988,CDM,250,RC,Y7506,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,55,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,83.6,
HYDROCODONE/APAP 5MG/500MG-TAB,656989,CDM,250,RC,,,Outpatient,5500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZOVIRAX 5% OINT-3GM,656990,CDM,250,RC,Y7506,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,22.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
ZOVIRAX 5% CREAM-2GM,656991,CDM,250,RC,Y7506,HCPCS,Outpatient,,,955,668.5,,,,,,Other,Not Seperately Reimbusable,649.4,68,,519.52,Percent of Total Billed Charges,68% of Total Billed Charges,725.8,76,,580.64,Percent of Total Billed Charges,76% of Total Billed Charges,477.5,50,,382,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,477.5,725.8,
ZONISAMIDE 35MG CAP,656994,CDM,250,RC,,,Outpatient,35,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
ALLOPURINOL 100MG-TAB,657000,CDM,250,RC,,,Outpatient,100,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALLOPURINOL 300MG TAB,657050,CDM,250,RC,,,Outpatient,300,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZYMAR 0.3% DROPS,657060,CDM,250,RC,Y7506,HCPCS,Outpatient,,,286,200.2,,,,,,Other,Not Seperately Reimbusable,194.48,68,,155.58,Percent of Total Billed Charges,68% of Total Billed Charges,217.36,76,,173.89,Percent of Total Billed Charges,76% of Total Billed Charges,143,50,,114.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143,217.36,
OLANZAPINE 5MG TAB,657065,CDM,250,RC,,,Outpatient,5,ME,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
ZYPREXA ZYDIS 20MG TAB,657070,CDM,250,RC,,,Outpatient,20,ME,138,96.6,,,,,,Other,Not Seperately Reimbusable,93.84,68,,75.07,Percent of Total Billed Charges,68% of Total Billed Charges,104.88,76,,83.9,Percent of Total Billed Charges,76% of Total Billed Charges,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,89.7,65,,71.76,Percent of Total Billed Charges,65% of Total Billed Charges,103.5,75,,82.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,82.8,60,,66.24,Percent of Total Billed Charges,60% of Total Billed Charges,28.15,20.4,,22.52,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,28.15,20.4,,22.52,Percent of Total Billed Charges,20.4% of Total Billed Charges,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.6,20,,22.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.6,104.88,
OLANZAPINE 10MG TAB,657075,CDM,250,RC,,,Outpatient,10,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
ZYRTEC SYRUP 1MG/ML SYRUP,657078,CDM,250,RC,,,Outpatient,1,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZYRTEC 10 MG -TAB,657079,CDM,250,RC,,,Outpatient,10,ME,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
OLOPATADINE 0.2% OPH SOL,657080,CDM,250,RC,,,Outpatient,,,119,83.3,,,,,,Other,Not Seperately Reimbusable,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,59.5,50,,47.6,Percent of Total Billed Charges,50% of Total Billed Charges,77.35,65,,61.88,Percent of Total Billed Charges,65% of Total Billed Charges,89.25,75,,71.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,20,,19.04,Percent of Total Billed Charges,20% of Total Billed Charges,71.4,60,,57.12,Percent of Total Billed Charges,60% of Total Billed Charges,24.28,20.4,,19.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.28,20.4,,19.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,23.8,20,,19.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,20,,19.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,23.8,90.44,
OLOPATADINE 0.7% OPHT,657081,CDM,250,RC,,,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,19.5,65,,15.6,Percent of Total Billed Charges,65% of Total Billed Charges,22.5,75,,18,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,18,60,,14.4,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,20.4,,4.9,Percent of Total Billed Charges,20.4% of Total Billed Charges,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,4.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,22.8,
FLUVOXAMINE 100MG TAB,657083,CDM,250,RC,,,Outpatient,100,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ZYVOX 600MG TABLET,657090,CDM,250,RC,,,Outpatient,600,ME,343,240.1,,,,,,Other,Not Seperately Reimbusable,233.24,68,,186.59,Percent of Total Billed Charges,68% of Total Billed Charges,260.68,76,,208.54,Percent of Total Billed Charges,76% of Total Billed Charges,171.5,50,,137.2,Percent of Total Billed Charges,50% of Total Billed Charges,222.95,65,,178.36,Percent of Total Billed Charges,65% of Total Billed Charges,257.25,75,,205.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,205.8,60,,164.64,Percent of Total Billed Charges,60% of Total Billed Charges,69.97,20.4,,55.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,69.97,20.4,,55.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,20,,54.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,68.6,260.68,
CELEXA 40MG TABLET,699312,CDM,250,RC,,,Outpatient,40,ME,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
GRANISETRON 1MG TAB,893644,CDM,250,RC,,,Outpatient,1,ME,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
EMPAGLIFLOZIN 10MG TAB,893662,CDM,250,RC,,,Outpatient,10,ME,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,69.55,65,,55.64,Percent of Total Billed Charges,65% of Total Billed Charges,80.25,75,,64.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,64.2,60,,51.36,Percent of Total Billed Charges,60% of Total Billed Charges,21.83,20.4,,17.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.83,20.4,,17.46,Percent of Total Billed Charges,20.4% of Total Billed Charges,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.4,20,,17.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.4,81.32,
CHAMBER HUMIDIFICATION AUTO FE,850452,CDM,250,RC,A4620,HCPCS,Outpatient,,,12,8.4,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
SINGLE LIMB HEATED CIRCUIT,850453,CDM,250,RC,Y7506,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
DUAL LIMB HEATED CIRCUIT,850454,CDM,250,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
HIGH FLOW NC LARGE,850455,CDM,250,RC,A4620,HCPCS,Outpatient,,,28,19.6,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
HIGH FLOW NC MEDIUM,850456,CDM,250,RC,A4620,HCPCS,Outpatient,,,28,19.6,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
HIGH FLOW NC SMALL,850457,CDM,250,RC,A4620,HCPCS,Outpatient,,,29,20.3,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
MUCOMYST,850720,CDM,250,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
INHALATION WATER 2000ML,850872,CDM,250,RC,A4620,HCPCS,Outpatient,2000,ML,7,4.9,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
INHALATION WATER 1000ML,850873,CDM,250,RC,A4620,HCPCS,Outpatient,1000,ML,5,3.5,,0.44,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
ALBUTEROL INH SOL 2.5MG/O.5MG,852357,CDM,250,RC,J7620,HCPCS,Outpatient,255,ME,49,34.3,,0.19,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
LEVALBUTEROL 1.25MG/3ML INH,852358,CDM,250,RC,,,Outpatient,1253,ME,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
ALBUTEROL SULFATE 0.83%/3ML,852359,CDM,250,RC,J7613,HCPCS,Outpatient,833,ML,49,34.3,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
IPRATROPIUM BROMIDE .02%/2.5ML,852360,CDM,250,RC,,,Outpatient,5,ML,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
RACEPINEPHRINE 2.25%/0.5ML INH,852361,CDM,250,RC,Y7506,HCPCS,Outpatient,5,ML,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
ACETYLCYSTEINE 20%/30ML,852362,CDM,250,RC,Y7506,HCPCS,Outpatient,2030,ML,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PULMICORT,852365,CDM,250,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
LUERLOCK SET,69600,CDM,253,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,28.6,Other,Not Seperately Reimbusable,,,,33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
MECLIZINE HCL 25MG TABLET,628670,CDM,253,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,469.98,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
METHERGINE 0.2MG TAB,629400,CDM,253,RC,,,Outpatient,2,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
IBUPROFEN TABLET 600MG,630350,CDM,253,RC,,,Outpatient,600,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,173.89,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
MS CONTIN 30MG TABLET,630353,CDM,253,RC,,,Outpatient,30,ME,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
NITROGLYCERIN TAB,633500,CDM,253,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
PENCILLIN-VK 500 MG -TAB,636200,CDM,253,RC,,,Outpatient,500,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,297.57,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PROVERA 10MG TAB,640600,CDM,253,RC,,,Outpatient,10,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SPIRONOLACTONE 25MG TABLET,645910,CDM,253,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 0.125-TAB,647510,CDM,253,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
SYNTHROID 25MCG TABLET,647640,CDM,253,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SYNTHROID 175MCG TAB,647665,CDM,253,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
THERAPEUTIC MVI TAB,650025,CDM,253,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
VITAMIN C 500MG-TAB,655676,CDM,253,RC,,,Outpatient,500,ME,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,239.36,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
ALPRAZOLAM .05MG TABLET,656309,CDM,253,RC,,,Outpatient,5,ME,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
ALPRAZOLAM 0.25MG-TAB,656310,CDM,253,RC,,,Outpatient,25,ME,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ZOLOFT 50MG TAB,656978,CDM,253,RC,,,Outpatient,50,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
L.R. 500ML,213500,CDM,258,RC,,,Outpatient,500,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,28.29,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
NORMOSOL-M/D5W 1000ML IV,213850,CDM,258,RC,J7030,HCPCS,Outpatient,1000,ML,63,44.1,,2.96,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,29.92,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,23.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
NORMOSOL-R 1000ML,213900,CDM,258,RC,J7030,HCPCS,Outpatient,1000,ML,84,58.8,,2.96,100,,,fee schedule,100% Aetna Market fee schedule,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
NORMOSOL-R/D5W 500,213935,CDM,258,RC,J7040,HCPCS,Outpatient,,,76,53.2,,1.48,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,32.1,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
NORMOSOL-R/D5W 1000,213950,CDM,258,RC,J7030,HCPCS,Outpatient,,,76,53.2,,2.96,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
NORMSL-R PH 7.4 500,214035,CDM,258,RC,J7040,HCPCS,Outpatient,,,76,53.2,,1.48,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,57.76,76,,39.17,Percent of Total Billed Charges,76% of Total Billed Charges,38,50,,693.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,57.76,
NORMSL-R PH 7.4 1000,214050,CDM,258,RC,J7030,HCPCS,Outpatient,,,90,63,,2.96,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,15.78,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
HYPERTONIC SALINE 3% 500ML IV,214100,CDM,258,RC,,,Outpatient,500,ML,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,26.11,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
NORMAL SALINE 100ML IV,214150,CDM,258,RC,J7050,HCPCS,Outpatient,100,ML,35,24.5,YA,0.74,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
NORMAL SALINE 0.9% 50ML ADV,214275,CDM,258,RC,J7050,HCPCS,Outpatient,50,ML,27,18.9,,0.74,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
NORMAL SALINE 0.9% 100ML ADV,214280,CDM,258,RC,,,Outpatient,100,ML,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,5.44,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
NORMAL SALINE 250ML IV,214282,CDM,258,RC,J7050,HCPCS,Outpatient,50,ML,35,24.5,,0.74,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
NORMAL SALINE 0.9% 250ML ADV,214285,CDM,258,RC,J7050,HCPCS,Outpatient,50,ML,27,18.9,,0.74,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,28.29,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
1/2 NORMAL SALINE 1000ML IV,214300,CDM,258,RC,,,Outpatient,1000,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
1/2 NORMAL SALINE 500ML INJ,214305,CDM,258,RC,,,Outpatient,500,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,147.42,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,31.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
SODIUM CHLORIDE 5% 500ML,214350,CDM,258,RC,J7040,HCPCS,Outpatient,500,ML,53,37.1,,1.48,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,151.78,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,47.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
NORMAL SALINE 1000CC,32800,CDM,258,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
NORMAL SALINE W/ 20MEQ KCL  10,633760,CDM,258,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
NORMAL SALINE W 40 MEQ KCL  10,633761,CDM,258,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
NORMAL SALINE 50ML MINIBAGP IN,633762,CDM,258,RC,,,Outpatient,50,ML,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
SODIUM CHLORIDE INJ 100MEQ,645209,CDM,258,RC,J7130,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SODIUM CHLORIDE 0.9% VIA FLEX,645220,CDM,258,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
SODIUM CHLORIDE 0.9% EXCEL 250,654212,CDM,258,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,179.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
BEBTELOVIMAB INFUSION OR INJEC,5722,CDM,260,RC,M0222,HCPCS,Outpatient,,,1352,946.4,,350.5,100,,,fee schedule,100% Aetna Market fee schedule,919.36,68,,735.49,Percent of Total Billed Charges,68% of Total Billed Charges,1027.52,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,676,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,332.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.7,100,,,Fee Schedule,100% of CMS OPPS Rate,332.7,1027.52,
REGENERON INFUSION OR INJ INIT,5723,CDM,260,RC,M0243,HCPCS,Outpatient,,,1353,947.1,,450,100,,,fee schedule,100% Aetna Market fee schedule,920.04,68,,736.03,Percent of Total Billed Charges,68% of Total Billed Charges,1028.28,76,,22.3,Percent of Total Billed Charges,76% of Total Billed Charges,676.5,50,,23.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,577.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,427.63,1028.28,
REGENERON INFUSION OR INJ REPE,5724,CDM,260,RC,M0244,HCPCS,Outpatient,,,1353,947.1,,750,100,,,fee schedule,100% Aetna Market fee schedule,920.04,68,,736.03,Percent of Total Billed Charges,68% of Total Billed Charges,1028.28,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,676.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,712.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.4,100,,,Fee Schedule,100% of CMS OPPS Rate,676.5,1028.28,
RX EVUSHELD INFSN W POST ADMIN,654274,CDM,260,RC,M0220,HCPCS,Outpatient,,,453,317.1,,150.5,100,,,fee schedule,100% Aetna Market fee schedule,308.04,68,,246.43,Percent of Total Billed Charges,68% of Total Billed Charges,344.28,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,226.5,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.86,100,,,Fee Schedule,100% of CMS OPPS Rate,142.86,344.28,
IV INFUSION THX/PX/DX FIRST HO,5729,CDM,260,RC,96365,HCPCS,Outpatient,,,350,245,,61.42,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,480.93,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,109.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,109.78,266,
IV INFUSION HYDRATION 1ST HR,5731,CDM,260,RC,96360,HCPCS,Outpatient,,,350,245,,31.12,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,170.85,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,57.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,57.14,266,
IV INFUSION THX/PX/DX EA ADDTL,5732,CDM,260,RC,96366,HCPCS,Outpatient,,,114,79.8,,19.23,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,36.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,36.64,86.64,
IV PUSH ONE/FIRST DRUG,5733,CDM,260,RC,96374,HCPCS,Outpatient,,,350,245,,35.73,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,64.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.74,266,
IV INFUSION HYDRATION EA ADDTL,5736,CDM,260,RC,96361,HCPCS,Outpatient,,,114,79.8,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,22.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,22.08,86.64,
IV INFUSION CONCURRENT,5737,CDM,260,RC,96368,HCPCS,Outpatient,,,390,273,,18.6,100,,,fee schedule,100% Aetna Market fee schedule,265.2,68,,212.16,Percent of Total Billed Charges,68% of Total Billed Charges,296.4,76,,185.44,Percent of Total Billed Charges,76% of Total Billed Charges,195,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.4,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.4,296.4,
IV PUSH EA ADDL DRUG,5738,CDM,260,RC,96375,HCPCS,Outpatient,,,114,79.8,,14.51,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,27.32,86.64,
IV PUSH SAME DRUG/SUB,5739,CDM,260,RC,96376,HCPCS,Outpatient,,,390,273,,9.29,100,,,fee schedule,100% Aetna Market fee schedule,265.2,68,,212.16,Percent of Total Billed Charges,68% of Total Billed Charges,296.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,195,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,296.4,
IV INFUS ADDL SEQ TO 1 HR,5742,CDM,260,RC,96367,HCPCS,Outpatient,,,181,126.7,,27.48,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,137.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,50.46,137.56,
INJECT THER DX INTRA ARTERIAL,5743,CDM,260,RC,96373,HCPCS,Outpatient,,,551,385.7,,16.46,100,,,fee schedule,100% Aetna Market fee schedule,374.68,68,,299.74,Percent of Total Billed Charges,68% of Total Billed Charges,418.76,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,275.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,33.68,418.76,
HEMOTX ADMIN SUBQ/IM HORMONAL,5836,CDM,260,RC,96402,HCPCS,Outpatient,,,190,133,,31.21,100,,,fee schedule,100% Aetna Market fee schedule,129.2,68,,103.36,Percent of Total Billed Charges,68% of Total Billed Charges,144.4,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,95,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,62.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,62.54,144.4,
IV INF THER PROPH ADL SEQL TO,893670,CDM,260,RC,96367,HCPCS,Outpatient,,,202,141.4,,27.48,100,,,fee schedule,100% Aetna Market fee schedule,137.36,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,153.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,101,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,50.46,153.52,
IV INFUS HYDRAT INIT 31 MIN TO,9636000,CDM,260,RC,96360,HCPCS,Outpatient,,,105,73.5,,31.12,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,57.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,52.5,261.69,
WESTMED AIRWAY HUMIDIFER,60377,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PRIMARY MICRODRIP SET,212050,CDM,270,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,165.98,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,109.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
ANTI-EM STKG LG-LONG,10350,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
STOCKING ANTI EMBOLISM;KNEE;LA,10400,CDM,270,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
STOCKING ANTI-EMBOLISM;THIGH;S,10401,CDM,270,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
STOCKING ANTI EMBOLISM;KNEE;ME,10402,CDM,270,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
"ANTI-EMB THIGH, LARGE, SHORT",10450,CDM,270,RC,,,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
ANTI-EM STKG MD-LONG,10500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ANTI-EM STKG MD-REG,10550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ANTI-EM STKG MD-SHRT,10600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ANTI-EM STKG SM-LONG,10650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
STOCKING ANTI EMBOLISM;KNEE;SM,10700,CDM,270,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
ANTI-EM STKG SM-SHRT,10750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ANTI-EM STKG XL,10800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,52,36.4,,,,,,Other,Not Seperately Reimbusable,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,39.52,
ANTI-EM STKG XXL,10820,CDM,270,RC,Y7506,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
STOCKING ANTI EMBOLISM;THIGH;L,10825,CDM,270,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
JOBST SUPPORT STKG.,10850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,234,163.8,,,,,,Other,Not Seperately Reimbusable,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,177.84,
ARM-CAST-LONG,11050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
ARM CAST-SHORT,11100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
BODY CAST,11150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
CAST APPLICATION,11200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
"CAST PADDING-3""",11215,CDM,270,RC,Y7508,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
"CAST PADDING -4""",11220,CDM,270,RC,Y7508,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
CAST REMOVAL-LONG,11250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CAST REMOVAL-SHORT,11300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.08,Other,Not Seperately Reimbusable,,,,17.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CASTING TAPE-2 IN,11310,CDM,270,RC,Y7508,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
CASTING TAPE-3 IN,11315,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
CASTING TAPE-4 IN,11320,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CASTING TAPE-5 IN,11325,CDM,270,RC,Y7508,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
CAST CYLINDER,11332,CDM,270,RC,Y7508,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,36.4,Other,Not Seperately Reimbusable,,,,42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,33.6,Other,Not Seperately Reimbusable,,,,11.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.42,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
HANGING CAST,11350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
LEG CAST-LONG,11400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
LEG CAST-SHORT,11450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
LEG PLATE PAD DISP,11465,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUGAR TONG CAST,11500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PLASTER ORTHA FLEX 4,11501,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PLASTER ORTHO FLEX 5,11502,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,26,Other,Not Seperately Reimbusable,,,,30,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PLASTER SPLINTS 3X15,11503,CDM,270,RC,Y7508,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
PLASTER SPLINTS 4X15,11504,CDM,270,RC,Y7508,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PLASTER SPLINTS 5X30,11505,CDM,270,RC,Y7508,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PLASTER SPLINTS 5X45,11506,CDM,270,RC,Y7508,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
"SPLINT, OCL 6""",11517,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
"SPLINT, OCL 4""",11521,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
"SPLINT, OCL 3""",11523,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
BALLOON DILATOR,11744,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
BALLOON DILATOR CATH,11750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,533,373.1,,,,,,Other,Not Seperately Reimbusable,362.44,68,,289.95,Percent of Total Billed Charges,68% of Total Billed Charges,405.08,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,266.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.5,405.08,
BALLOON DILAT-PYLORI,11760,CDM,270,RC,Y7506,HCPCS,Outpatient,,,400,280,,,,,,Other,Not Seperately Reimbusable,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,304,
CATHET.-COUNCILL TIP,11800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
BARRIER W/ FLANGE,11810,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.56,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,13.44,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
CHEST DRAINAGE UNIT,11900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
CHOLANGEIOGRAM CATH,11950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
COLON TUBE,12000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
CONDUCTIVE SUCT. TBS,12050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.96,Other,Not Seperately Reimbusable,,,,13.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,11.04,Other,Not Seperately Reimbusable,,,,3.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.75,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CONNECTING TUBE 3/16,12100,CDM,270,RC,A9900,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,76.61,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.96,Other,Not Seperately Reimbusable,,,,13.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,11.04,Other,Not Seperately Reimbusable,,,,3.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.75,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
COUDE CATHETER,12115,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,420.74,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,276.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
DEE LEE CATHETER 8FR,12200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
DEE LE-CATHETER 10FR,12250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
DEE LE-CATHETER 12FR,12300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DEE LEE CATH 14FR,12320,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
D-L-CATH.-MUCUS TRAP,12350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
DRAIN CLIP,12400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.36,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
EFFECTIVE CAP,12425,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.84,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,20.16,Other,Not Seperately Reimbusable,,,,6.86,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.86,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
ESOPH-BLAKEMORE TUBE,12450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,52.29,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.84,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,20.16,Other,Not Seperately Reimbusable,,,,6.86,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.86,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
EYE WICK DRAIN,12475,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
EXTENSION SET 1.2MICROFILTER 7,12480,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,200,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
FEEDING SET PREM-INF,12500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
FEEDING TUBES 5FR,12550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FEEDING TUBES 8FR,12600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,31.72,Other,Not Seperately Reimbusable,,,,36.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.76,Other,Not Seperately Reimbusable,,,,29.28,Other,Not Seperately Reimbusable,,,,9.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.95,Other,Not Seperately Reimbusable,,,,9.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
"FLAT DRN 7X4MM 3/4""",12630,CDM,270,RC,Y7506,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
FLT DRN 7X4MM FUL LG,12632,CDM,270,RC,Y7506,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
"FLT DRN 10X4MM 3/4""",12634,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
FLT DRN 10X4M FUL LG,12636,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
HEYER-SCHULTE SUC RS,12640,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
GASTRIC CHAR-FLO,12646,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
GASTRIC LAVAGE SYST,12648,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
GASTRIC SUMP TUBE,12650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.36,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
HEIMLICH VALVE,12675,CDM,270,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.16,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,27.84,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
INFUS OR PUMP/TUBING,12686,CDM,270,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,84.51,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
INGRAM-TROCAR-C-12FR,12700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
INGRAM-TROCAR-C-16FR,12750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
LEVACUATOR TUBE,12800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
LEVINE TUBE 5FR,12850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
LIFESHIELD STERILE CAP,12875,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
MILLER ABBOTT TUBE,12900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
MUCOUS TRAP,12933,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
MUSHROOM CATHETER,12950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
PENROSE DRAIN,13000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.6,Other,Not Seperately Reimbusable,,,,18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
PENROSE DRAIN 1/2X12,13050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,57.2,Other,Not Seperately Reimbusable,,,,66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,52.8,Other,Not Seperately Reimbusable,,,,17.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.95,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PENROSE DRAIN 5/8X12,13100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,215.28,Other,Not Seperately Reimbusable,,,,248.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,66.24,Other,Not Seperately Reimbusable,,,,198.72,Other,Not Seperately Reimbusable,,,,67.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.57,Other,Not Seperately Reimbusable,,,,66.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,66.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
PENROSE DRAIN 5/8X18,13150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,67.6,Other,Not Seperately Reimbusable,,,,78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.8,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,21.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.22,Other,Not Seperately Reimbusable,,,,20.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PENROSE DRAIN 5/8X36,13200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
PENROSE DRAIN 1 X 18,13250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PERITONEAL CATH.11FR,13275,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1216.8,Other,Not Seperately Reimbusable,,,,1404,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,374.4,Other,Not Seperately Reimbusable,,,,1123.2,Other,Not Seperately Reimbusable,,,,381.89,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,381.89,Other,Not Seperately Reimbusable,,,,374.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,374.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
PREP PAD,13284,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
REDD CELL FLTR/TBG,13290,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
RED RUBBER CATH 8FR,13300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
RED RUBBER CATH 10FR,13350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
RED RUBBER CATH 12FR,13400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
RED RUBBER CATH 14FR,13450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1344.2,Other,Not Seperately Reimbusable,,,,1551,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,413.6,Other,Not Seperately Reimbusable,,,,1240.8,Other,Not Seperately Reimbusable,,,,421.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,421.87,Other,Not Seperately Reimbusable,,,,413.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,413.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
RED RUBBER CATH 16FR,13500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,75.92,Other,Not Seperately Reimbusable,,,,87.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.36,Other,Not Seperately Reimbusable,,,,70.08,Other,Not Seperately Reimbusable,,,,23.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.82,Other,Not Seperately Reimbusable,,,,23.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RED RUBBER CATH 18FR,13550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,207.48,Other,Not Seperately Reimbusable,,,,239.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,191.52,Other,Not Seperately Reimbusable,,,,65.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,65.12,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RED RUBBER CATH 20FR,13600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.24,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
RED RUBBER CATH 22FR,13650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
RED RUBBER CATH 24FR,13700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
RED RUBBER CATH 26FR,13750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SALEM SUMP TUBE 10FR,13900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SALEM SUMP TUBE 12FR,13950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,327.6,Other,Not Seperately Reimbusable,,,,378,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,302.4,Other,Not Seperately Reimbusable,,,,102.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,102.82,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
14FR SALEM SUMP TUBE,14000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
10ML RADIOFREQUENCY NEEDLE,14025,CDM,270,RC,Y7506,HCPCS,Outpatient,10,ML,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.08,Other,Not Seperately Reimbusable,,,,137.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.64,Other,Not Seperately Reimbusable,,,,109.92,Other,Not Seperately Reimbusable,,,,37.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.38,Other,Not Seperately Reimbusable,,,,36.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
16FR SALEM SUMP TUBE,14050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
18FR SALEM SUMP TUBE,14100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SARATOGA SUMP DRAIN,14114,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SHIRLEY WOUND DRAIN,14150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
SIGMOID SUCTION UNIT,14200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SUCT CATH ADAPTR/SVL,14220,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,50.44,Other,Not Seperately Reimbusable,,,,58.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,46.56,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SUCT CUR ENDOMETRIAL,14240,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
SUCTION CATH. 5FR,14250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUCTION CATH 8FR,14275,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SUCTION CATH. 10FR,14300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,23.4,Other,Not Seperately Reimbusable,,,,27,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SUCTION CATH. 14FR,14350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
SUCTION CATH. 16FR,14400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,23.4,Other,Not Seperately Reimbusable,,,,27,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUCTION CATH. 18FR,14450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SUCT. CATH. KIT 14FR,14500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SUCTION TUBING 3/16,14550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3092.29,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2034.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,40.56,Other,Not Seperately Reimbusable,,,,46.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUCTION TUBING 1/4,14600,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,40.56,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
THORACIC CATHETER STRAIGHT,14650,CDM,270,RC,C1729,HCPCS,Outpatient,,,27,18.9,,11.1,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,40.56,Other,Not Seperately Reimbusable,,,,46.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
THORACIC TROCAR CATH,14700,CDM,270,RC,C1729,HCPCS,Outpatient,,,17,11.9,,11.1,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
THORACIC VENT TRAY,14710,CDM,270,RC,Y7506,HCPCS,Outpatient,,,506,354.2,,,,,,Other,Not Seperately Reimbusable,344.08,68,,275.26,Percent of Total Billed Charges,68% of Total Billed Charges,384.56,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,253,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,669.76,Other,Not Seperately Reimbusable,,,,772.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,618.24,Other,Not Seperately Reimbusable,,,,210.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,210.2,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253,384.56,
TROCAR CATHETER,14725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,559,Other,Not Seperately Reimbusable,,,,645,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,516,Other,Not Seperately Reimbusable,,,,175.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,175.44,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
TUBG-CONNECTORS 5-1,14750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,860.08,Other,Not Seperately Reimbusable,,,,992.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,793.92,Other,Not Seperately Reimbusable,,,,269.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,269.94,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
TUBG-CONNECTORS 6-1,14800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,374.4,Other,Not Seperately Reimbusable,,,,432,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,115.2,Other,Not Seperately Reimbusable,,,,345.6,Other,Not Seperately Reimbusable,,,,117.5,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,117.5,Other,Not Seperately Reimbusable,,,,115.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,115.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TUBG-CONNECTOR Y-TYP,14850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,156,Other,Not Seperately Reimbusable,,,,180,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48,Other,Not Seperately Reimbusable,,,,144,Other,Not Seperately Reimbusable,,,,48.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48.96,Other,Not Seperately Reimbusable,,,,48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
T - DRAIN,14900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
UMBL.ARTERY CATH 3.5,15000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,122.72,Other,Not Seperately Reimbusable,,,,141.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,113.28,Other,Not Seperately Reimbusable,,,,38.51,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.51,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
UMBL.ARTERY CATH 5.0,15050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
URETERAL CATH. DISP.,15100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.96,Other,Not Seperately Reimbusable,,,,43.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,35.04,Other,Not Seperately Reimbusable,,,,11.91,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.91,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
URETERAL STENT,15125,CDM,270,RC,Y7506,HCPCS,Outpatient,,,186,130.2,,,,,,Other,Not Seperately Reimbusable,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,141.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93,141.36,
URET STENT-LUBRIFLEX,15135,CDM,270,RC,Y7506,HCPCS,Outpatient,,,301,210.7,,,,,,Other,Not Seperately Reimbusable,204.68,68,,163.74,Percent of Total Billed Charges,68% of Total Billed Charges,228.76,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,150.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.5,228.76,
WOUND SUCTION SET,15150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
YANKAUER SUCTION TB,15200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
WECK BLADE,15205,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
WECK SUCTION TUBE,15209,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
POOL SUCTION,15210,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ALCOHOL-PINT,15400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
AMPLATZ DILATORS,15500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,535,374.5,,,,,,Other,Not Seperately Reimbusable,363.8,68,,291.04,Percent of Total Billed Charges,68% of Total Billed Charges,406.6,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,267.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.5,406.6,
BENZOINE COMPOUND,15550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,314.34,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,206.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
BETADINE GAUZE PAD,15560,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
BETADINE SCRUB 16 OZ,15700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
BETADINE PREP,15750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
BETADINE SLTN-16 OZ,15800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
BETADINE SWAB STICKS,15850,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
HYDROCHLOR,15900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,138.02,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
HIBICLENS PREP,16200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,871.87,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,573.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HIBITANE TINC 4OZ,16250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PEROXIDE,16300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PHISODERM 5OZ,16350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PHISOHEX 5 OZ,16400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
PHISOHEX 16 OZ,16450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
PHISOHEX-PINT,16500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
SCRUB BRUSH 101,16550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SCRUB BRUSH 201,16600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,23.4,Other,Not Seperately Reimbusable,,,,27,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.34,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SCRUB BRUSH 160,16650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,70.2,Other,Not Seperately Reimbusable,,,,81,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,64.8,Other,Not Seperately Reimbusable,,,,22.03,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.03,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SEPTISOL PREP,16700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.96,Other,Not Seperately Reimbusable,,,,43.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,35.04,Other,Not Seperately Reimbusable,,,,11.91,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.91,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SHAMPOO SWEEN 4 OZ,16718,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SHUR-CLENS W/SPONGE,16725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
SWEEN CREAM,16750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
BARD MESH PERFIX PLUG M-L 2/BO,16800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,506,354.2,,,,,,Other,Not Seperately Reimbusable,344.08,68,,275.26,Percent of Total Billed Charges,68% of Total Billed Charges,384.56,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,253,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253,384.56,
BARD MESH PERFIX X-LARGE 2/BOX,16810,CDM,270,RC,Y7509,HCPCS,Outpatient,,,586,410.2,,,,,,Other,Not Seperately Reimbusable,398.48,68,,318.78,Percent of Total Billed Charges,68% of Total Billed Charges,445.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,293,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293,445.36,
STAPHENE,16950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ADAPT PASTE,17250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ADAPTIC PKNG STRPS,17300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ADAPTIC DRSNG 3X3,17350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ADAPTIVE UTENSILS,17399,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
ADAPTIC DRSNG 3X8,17400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,89.44,Other,Not Seperately Reimbusable,,,,103.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.52,Other,Not Seperately Reimbusable,,,,82.56,Other,Not Seperately Reimbusable,,,,28.07,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.07,Other,Not Seperately Reimbusable,,,,27.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ADAPTIC DRSNG 3X16,17404,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,47.32,Other,Not Seperately Reimbusable,,,,54.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,43.68,Other,Not Seperately Reimbusable,,,,14.85,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.85,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
AEROPLAST SPRAY USE,17450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,54.08,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,49.92,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ALLEVYN NON ADHESIVE 6X6,17460,CDM,270,RC,,,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.9,65,,67.6,Percent of Total Billed Charges,65% of Total Billed Charges,4.5,75,,78,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,3.6,60,,62.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.22,20.4,,21.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.22,20.4,,21.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.2,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.2,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.2,4.56,
"BANDAGE-STERILE 3""",17589,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BANDAIDS 2,17600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
DRESSING 3.5 X 8,17750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BARRIER PREP PAD,17800,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
BURNGEL DRSG MASK,17825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
BURNGEL DRSG TOWEL,17826,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
CLEARSITE BRDR DRSG,17833,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,55.12,Other,Not Seperately Reimbusable,,,,63.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.96,Other,Not Seperately Reimbusable,,,,50.88,Other,Not Seperately Reimbusable,,,,17.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.3,Other,Not Seperately Reimbusable,,,,16.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
CLINIPAD DRESS CHNG,17834,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
COTTON ROLL,17835,CDM,270,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
DRESSING 3.5 X 10,17836,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.36,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DRSG COMP. PROFORE,17837,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
DRESSING-TELFA ADHESIVE ISLAND,17839,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,69.16,Other,Not Seperately Reimbusable,,,,79.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,21.7,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.7,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
"ELASTIC BNDG 4""X11'",17840,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,860.08,Other,Not Seperately Reimbusable,,,,992.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,793.92,Other,Not Seperately Reimbusable,,,,269.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,269.94,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,264.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
"ELASTIC BNDG 6""X11'",17842,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,559,Other,Not Seperately Reimbusable,,,,645,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,516,Other,Not Seperately Reimbusable,,,,175.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,175.44,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ELASTIC BNDG-SELF AD,17845,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,669.76,Other,Not Seperately Reimbusable,,,,772.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,618.24,Other,Not Seperately Reimbusable,,,,210.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,210.2,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,206.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ELASTOPLAT 4,18050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
FERRIS POLYMEM DRSNG,18080,CDM,270,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,819.52,Other,Not Seperately Reimbusable,,,,945.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,252.16,Other,Not Seperately Reimbusable,,,,756.48,Other,Not Seperately Reimbusable,,,,257.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,257.2,Other,Not Seperately Reimbusable,,,,252.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,252.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
FULLER SHIELDS,18100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
FURACIN STRIP 1 MIN4,18150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
FURACIN STRIP 4 MIN2,18200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
FURACIN PAN-SMALL 1,18250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
FURACIN PAN-SMALL 4,18300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,62.4,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,57.6,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
FURACIN PAN-LARGE 4,18350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
GAUZE SPONGE NS 3X3 12 PLY,18450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
GAUZE SPONGE-3X3 ST,18475,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
"GAUZE, TUBE",18500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
HICRODON/PAD 6 X 6,18532,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
HYDROGEL ISLND DRSG,18535,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
INTRO. GASTRO. KIT,18550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,400,280,,,,,,Other,Not Seperately Reimbusable,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200,304,
GEL HYDRO SKINTEGRITY 4 OZ TUB,18565,CDM,270,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
KERLIX GAUZE ROLLS,18600,CDM,270,RC,A6448,HCPCS,Outpatient,,,5,3.5,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
KLING 1 STERILE,18845,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
KLING 2 STERILE,18850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
KLING 3 STERILE,18900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,68.64,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,63.36,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
KLING 4 STERILE,18950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
KLING 6 STERILE,19000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MATERNITY PADS,19050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
MATER. PADS-STER.1'S,19100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
MEDIFIL,19120,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
MEDIHONEY 3.5 OZ W/ APPLICATOR,19125,CDM,270,RC,,,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
MONTGOMERY STRAPS,19150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
MULTI-DEX,19160,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
MULTI-TRAUMA DRSG,19175,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
DRSG TRANSPARENT SM,19249,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
DRSG TRANSPARENT LG,19250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
DRESSING AQUACEL AG 4X5IN,19251,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
DRESSING AQUACEL 5X4 HYDROFIBE,19252,CDM,270,RC,,,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
OPSITE SURG. DRAPE,19300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
DRESSING-BIOCLUS 4X5,19350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
OVAL EYE PADS,19400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.8,Other,Not Seperately Reimbusable,,,,39,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
PKNG.STRPS-PLAIN 1/4,19450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.08,Other,Not Seperately Reimbusable,,,,17.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PKNG.STRPS-PLAIN 1/2,19500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,22.36,Other,Not Seperately Reimbusable,,,,25.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,20.64,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
PKNG.STRPS-PLAIN 1,19550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.8,Other,Not Seperately Reimbusable,,,,39,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PKNG.STRPS-PLAIN 2,19600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,46.8,Other,Not Seperately Reimbusable,,,,54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,14.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.69,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PKG. STR-IODOFORM1/4,19650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
PKG. STR-IODOFORM1/2,19700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PKG. STR-IODOFORM 1,19750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,82.68,Other,Not Seperately Reimbusable,,,,95.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,76.32,Other,Not Seperately Reimbusable,,,,25.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.95,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
PKG. STR-IODOFORM 2,19800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.24,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
PETROLEUM GAUZE 1X8,19825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,63.96,Other,Not Seperately Reimbusable,,,,73.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,59.04,Other,Not Seperately Reimbusable,,,,20.07,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.07,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PETROLEUM GAUZE 1X36,19850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.28,Other,Not Seperately Reimbusable,,,,23.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,18.72,Other,Not Seperately Reimbusable,,,,6.37,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.37,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PETROLEUM GAUZE 3X18,19950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PLASTER BANDAGE 2,20000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,382.72,Other,Not Seperately Reimbusable,,,,441.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,117.76,Other,Not Seperately Reimbusable,,,,353.28,Other,Not Seperately Reimbusable,,,,120.11,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,120.11,Other,Not Seperately Reimbusable,,,,117.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,117.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
"PLASTER BANDAGE 3""",20050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2342.6,Other,Not Seperately Reimbusable,,,,2703,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,720.8,Other,Not Seperately Reimbusable,,,,2162.4,Other,Not Seperately Reimbusable,,,,735.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,735.22,Other,Not Seperately Reimbusable,,,,720.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,720.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PLASTER BANDAGE 4,20100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4400.24,Other,Not Seperately Reimbusable,,,,5077.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1353.92,Other,Not Seperately Reimbusable,,,,4061.76,Other,Not Seperately Reimbusable,,,,1381,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1381,Other,Not Seperately Reimbusable,,,,1353.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1353.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PLASTER BANDAGE 5,20150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,997.36,Other,Not Seperately Reimbusable,,,,1150.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,306.88,Other,Not Seperately Reimbusable,,,,920.64,Other,Not Seperately Reimbusable,,,,313.02,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,313.02,Other,Not Seperately Reimbusable,,,,306.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,306.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
PLASTER BANDAGE 6,20200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,933.92,Other,Not Seperately Reimbusable,,,,1077.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,862.08,Other,Not Seperately Reimbusable,,,,293.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,293.1,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
POLYSKIN II 2X2 3/4,20222,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2191.28,Other,Not Seperately Reimbusable,,,,2528.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,674.24,Other,Not Seperately Reimbusable,,,,2022.72,Other,Not Seperately Reimbusable,,,,687.73,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,687.73,Other,Not Seperately Reimbusable,,,,674.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,674.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
WOUND DRSG 4 X 4.75,20225,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,228.8,Other,Not Seperately Reimbusable,,,,264,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,70.4,Other,Not Seperately Reimbusable,,,,211.2,Other,Not Seperately Reimbusable,,,,71.81,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,71.81,Other,Not Seperately Reimbusable,,,,70.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,70.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
RAYTEC LAP SPG.18X18,20250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,270.4,Other,Not Seperately Reimbusable,,,,312,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.2,Other,Not Seperately Reimbusable,,,,249.6,Other,Not Seperately Reimbusable,,,,84.86,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,84.86,Other,Not Seperately Reimbusable,,,,83.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RUBBER ELASTIC BAND2,20400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,41.6,Other,Not Seperately Reimbusable,,,,48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.8,Other,Not Seperately Reimbusable,,,,38.4,Other,Not Seperately Reimbusable,,,,13.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.06,Other,Not Seperately Reimbusable,,,,12.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RUBBER ELASTIC BAND3,20450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,451.36,Other,Not Seperately Reimbusable,,,,520.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,138.88,Other,Not Seperately Reimbusable,,,,416.64,Other,Not Seperately Reimbusable,,,,141.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,141.66,Other,Not Seperately Reimbusable,,,,138.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,138.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RUBBER ELASTIC BAND4,20500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,122.72,Other,Not Seperately Reimbusable,,,,141.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,113.28,Other,Not Seperately Reimbusable,,,,38.51,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.51,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
RUBBER ELASTIC BAND6,20550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,933.92,Other,Not Seperately Reimbusable,,,,1077.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,862.08,Other,Not Seperately Reimbusable,,,,293.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,293.1,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,287.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
SALINE DRESSING,20625,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,98.8,Other,Not Seperately Reimbusable,,,,114,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,,,,91.2,Other,Not Seperately Reimbusable,,,,31.01,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.01,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SANITERY BELTS,20650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
"STRIP, NG ADULT",20670,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SKIN BARRIER WIPES,20685,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
SOFSORB WOUND DRSG.,20695,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SOFWICK 4X4,20700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SOLOSITE,20705,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SORBSAN TOPICAL DRSG,20712,CDM,270,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,47.32,Other,Not Seperately Reimbusable,,,,54.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,43.68,Other,Not Seperately Reimbusable,,,,14.85,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.85,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
SPONGE 2X2 8PLY,20720,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,42.12,Other,Not Seperately Reimbusable,,,,48.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,38.88,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
SPANDAGE-ELASTIC,20725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,42.12,Other,Not Seperately Reimbusable,,,,48.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,38.88,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SPONGES 4X4,20750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SPONGES 4X4 12PLY,20800,CDM,270,RC,A9900,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SPONGE RAYTIC 4X4,20850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SPONGE-TONSIL/EACH,20875,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
STERILE 4X4 12 PLY,20900,CDM,270,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
"STERILE ELASTIC 2""",20921,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
"STERILE ELASTIC 3""",20924,CDM,270,RC,Y7509,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
"STERILE ELASTIC 4""",20927,CDM,270,RC,Y7509,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
"STERILE ELASTIC 6""",20930,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
STERISTRIPS 1/8X 3,20950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
STERISTRIPS 1/4X 3,21000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
STERISTRIPS 1/2X4,21050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,695.55,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,457.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
STERISTRIPS 1X4,21100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
STOCKINETTE 2,21150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,85.8,Other,Not Seperately Reimbusable,,,,99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
STOCKINETTE 3,21200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
STOCKINETTE 4,21250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
STOCKINETTE 5,21300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HEPRN 10 USP UNIT,21330,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
STOCKINETTE 6,21350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
"STOCKINETTE 8""",21351,CDM,270,RC,Y7508,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
IMPERVIOUS STOCKING,21360,CDM,270,RC,Y7508,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SURGICEL,21400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,273,191.1,,,,,,Other,Not Seperately Reimbusable,185.64,68,,148.51,Percent of Total Billed Charges,68% of Total Billed Charges,207.48,76,,404.93,Percent of Total Billed Charges,76% of Total Billed Charges,136.5,50,,266.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.5,207.48,
SURGIPAD 8X10 COMBIN,21450,CDM,270,RC,A6441,HCPCS,Outpatient,,,3,2.1,,0.5,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,595.84,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,392,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TELFA ABD,21500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TELFA 3X4,21550,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
TELFA STRIPS SURG3X8,21650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TOPPER SPG NS 3X3 4P,21700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
TOPPERS 4X4 NON-STER,21750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1304.16,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,858,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
TOPPERS 4X4 STERILE,21800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TOWELS-STERILE 1 PK,21825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TUCKS-SMALL,21850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
TUCKS-LARGE,21900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
ULCER DR-VIASORB 4X6,21912,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ULCER DR-VIASORB 7X7,21914,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
ULCER DRESSING-EACH,21925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
TEGADERM/PAD 3.5 X 6,21938,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
WEBRIL 2,21950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
WEBRIL 3,22000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
WEBRIL 4,22050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
"WEBRIL 6""",22100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
"WEBRIL STERILE 3""",22106,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
"WEBRIL STERILE 6""",22112,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
WOUND DRESSING-1 OZ,22115,CDM,270,RC,Y7509,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
WOUND FILL TEGAGEL,22120,CDM,270,RC,Y7509,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
WOUND DRSG 2.75 X 3.5,22130,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
CAST-ARM LONG,22300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
CAST-ARM SHORT,22350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CAST-BODY,22400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
CAST-HANGING,22450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
CAST-LEG LONG,22500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
CAST-LEG SHORT,22550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CATHETERIZATION C&S,22600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CPAP-NASAL,22625,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
CPR W/RESUS.DR.HOUSE,22650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
"BIRTHING TRAY, EMERGENCY",22700,CDM,270,RC,,,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,22.04,
GASTRIC LAVAGE,22750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
GYN PELVIC-INPATIENT,22755,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MAJOR LAC. SET UP,22800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
MAJOR TRAY PROCEDURE,22850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
OB PADS-LARGE,22895,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
MINOR LAC. SET UP,22900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,102.14,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MINOR LAC. TRAY-DISP,22925,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
OB PROCEDURE W/DR,22950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
OB PROCEDURE W/O DR.,23000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
OB MOMMY PACK,23001,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
PROCTOSCOPIC EXAM,23050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
RECTAL EXAM W/GLOVE,23100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SUGAR TONG SPNT.PLST,23150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SUTURE REMOVAL TRAY,23200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
BASIC PACK-DISPO.,26100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,44.08,
BASK FOR FRN BODY R,26110,CDM,270,RC,Y7509,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
C-SECTION PACK-DISPO,26127,CDM,270,RC,Y7506,HCPCS,Outpatient,,,126,88.2,,,,,,Other,Not Seperately Reimbusable,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,95.76,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,63,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63,95.76,
C-SECT PACK LATEX FR,26130,CDM,270,RC,Y7506,HCPCS,Outpatient,,,692,484.4,,,,,,Other,Not Seperately Reimbusable,470.56,68,,376.45,Percent of Total Billed Charges,68% of Total Billed Charges,525.92,76,,122.21,Percent of Total Billed Charges,76% of Total Billed Charges,346,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,346,525.92,
CYSTO PACK-DISPO.,26150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
DADDY'S PACK,26375,CDM,270,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,71.24,Other,Not Seperately Reimbusable,,,,82.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,65.76,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
DAKINS SOLUTION,26390,CDM,270,RC,Y7506,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,122.21,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
DISPO. SLEEVE,26400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DRAPE HALF-SHEET,26555,CDM,270,RC,,,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
DRAPE ISOLATION 3M,26557,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,96.2,Other,Not Seperately Reimbusable,,,,111,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.6,Other,Not Seperately Reimbusable,,,,88.8,Other,Not Seperately Reimbusable,,,,30.19,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.19,Other,Not Seperately Reimbusable,,,,29.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
OPTHALMIC INCISE SHT,26558,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,130.52,Other,Not Seperately Reimbusable,,,,150.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.16,Other,Not Seperately Reimbusable,,,,120.48,Other,Not Seperately Reimbusable,,,,40.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.96,Other,Not Seperately Reimbusable,,,,40.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
EAR DRAPE,26560,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
EXTREMITY PACK-DISPO,26573,CDM,270,RC,Y7506,HCPCS,Outpatient,,,86,60.2,,,,,,Other,Not Seperately Reimbusable,58.48,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,65.36,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,43,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43,65.36,
EXTREMITY SHEET,26585,CDM,270,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
GEN PACK LATEX FR,26595,CDM,270,RC,Y7506,HCPCS,Outpatient,,,500,350,,,,,,Other,Not Seperately Reimbusable,340,68,,272,Percent of Total Billed Charges,68% of Total Billed Charges,380,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,250,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250,380,
GOWN-STERILE BACK,26600,CDM,270,RC,,,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,17.55,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,20.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,16.2,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,5.51,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.51,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.4,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.4,20.52,
HOUSE SHOES-DISP.,26650,CDM,270,RC,A4649,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,13.98,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ISOLATION FOLLOW-UP,26700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ISOL ENTERIC PREC,26701,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
ISOL PROTECTIVE,26702,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
ISOL RESPIRATORY,26703,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,13.98,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,9.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
ISOL STRICT,26704,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
ISOL DRAINAGE/SECR,26705,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
ISOL CONTACT,26706,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,133.76,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,88,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
ISOL BLOOD/BODY FL,26707,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
ISOL AFB,26708,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
ISOLATION GOWN,26750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ISOLATION KITS,26800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
LAP PACK-DISP.,26850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,139,97.3,,,,,,Other,Not Seperately Reimbusable,94.52,68,,75.62,Percent of Total Billed Charges,68% of Total Billed Charges,105.64,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,69.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.5,105.64,
ISOTONER THERAPETIC GLOVE(CLSD,26875,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
LAP SPONGE-DISP.,26900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
LITH PACK-DISP,26950,CDM,270,RC,,,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.5,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,52.5,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,42,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,14.28,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.28,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,14,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14,53.2,
MAJOR BASIN SET,26975,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
MASK FILTER BX OF 50,27050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
MASK-ISOL BOX OF 50,27075,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
MASK-N95 RESPIRATOR,27080,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
MAYO STAND COVER-DIS,27150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
OB LINEN PACK-DISPO,27200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
PROPPING DEVICE,27219,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ORTHOPEDIC PK -DISPO,27238,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
STERIDRAPE-ORTHO.,27340,CDM,270,RC,Y7509,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
STERIDRAPE LARGE,27350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
STERIDRAPE SMALL,27400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
U-DRAPE,27445,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
UNDERBUTTOX DRAPE,27450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CYSTO PACK,28050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,68.64,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,63.36,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
EYE SHEET,28200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
GOWN-STERILE,28550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
GOWN-STERILE XXLARGE,28570,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
LAP PACK,28600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
LAP SHEET,28650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
LITH PACK,28700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
MAYO COVER,28750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
MAYS STAND COVER,28800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
MCKASKLE DRAPE,28850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,153.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,101.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MCKEE DRAPE,28875,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,185.12,Other,Not Seperately Reimbusable,,,,213.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.96,Other,Not Seperately Reimbusable,,,,170.88,Other,Not Seperately Reimbusable,,,,58.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,58.1,Other,Not Seperately Reimbusable,,,,56.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
STERILE LINEN,30000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
COLD PACKS,30050,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
COLD THERAPY,30051,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
TOWELS STERILE 4PK,30100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
TOWEL STERILE REUSE,30130,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ADMISSION KIT,30500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,551.2,Other,Not Seperately Reimbusable,,,,636,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,169.6,Other,Not Seperately Reimbusable,,,,508.8,Other,Not Seperately Reimbusable,,,,172.99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172.99,Other,Not Seperately Reimbusable,,,,169.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,169.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
ADMISSION KIT-OB,30550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
ADULT DIAPERS,30575,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
ADULT DIAPER ATTENDS,30578,CDM,270,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
AEROPLAST,30600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ALCOHOL SWABSTICKS,30615,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ANTER-CHAMBER CANUL,30618,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ANTIFUNGAL CREAM,30621,CDM,270,RC,Y7506,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
APETAL CREAM/BTL,30625,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
BABY POWDER,30650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
BABY WIPES/PKG,30660,CDM,270,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
BATH BASIN,30668,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
BEANIE HAT,30670,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
BED PAN-DISPOSABLE,30700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
BED PAN-FRACTURE,30750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
BILI PAD COVER,30755,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
BILI MASK,30760,CDM,270,RC,Y7506,HCPCS,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
BITE STICKS,30775,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BLANKET WARMING,30785,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,88.4,Other,Not Seperately Reimbusable,,,,102,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.2,Other,Not Seperately Reimbusable,,,,81.6,Other,Not Seperately Reimbusable,,,,27.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.74,Other,Not Seperately Reimbusable,,,,27.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
BOOST,30790,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
BOOST PLUS,30795,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
BREAST BINDERS,30800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,76.44,Other,Not Seperately Reimbusable,,,,88.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,70.56,Other,Not Seperately Reimbusable,,,,23.99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.99,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BREAST PUMP,30850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
BREATHING FILTER,30860,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CARAFE,30900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
COMB,30904,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,71.24,Other,Not Seperately Reimbusable,,,,82.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,65.76,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
COMB LICE,30906,CDM,270,RC,Y7506,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
CRIB WARMER,30925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CORD CLAMPS,30950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
DECUBITUS PADS,31100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
DERMA SHIELD,31180,CDM,270,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
DERMOPLAST SPRAY,31200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
DISPOS-A-CUFF NEO,31240,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
DISPOS. BP CUFF,31245,CDM,270,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
DIGITEX SUTURE DELIVERY,31300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,517,361.9,,,,,,Other,Not Seperately Reimbusable,351.56,68,,281.25,Percent of Total Billed Charges,68% of Total Billed Charges,392.92,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,258.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.5,392.92,
EMESIS BASIN,31350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ENSURE,31360,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,74.36,Other,Not Seperately Reimbusable,,,,85.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.88,Other,Not Seperately Reimbusable,,,,68.64,Other,Not Seperately Reimbusable,,,,23.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.34,Other,Not Seperately Reimbusable,,,,22.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
FELT ORTHO-CASTING,31370,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
FEMALE SPECI CATH,31375,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,47.84,Other,Not Seperately Reimbusable,,,,55.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.72,Other,Not Seperately Reimbusable,,,,44.16,Other,Not Seperately Reimbusable,,,,15.02,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.02,Other,Not Seperately Reimbusable,,,,14.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FOOT COVER AV-IMP,31385,CDM,270,RC,Y7506,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
FOAM MAT-CASTING,31450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
GLOVES SURGEON,31700,CDM,270,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
GLOVES-STRL-DISPO.,31750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
GLOVES UNSTERILE-BOX,31800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
GRAD U FEED,31809,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
GLUCERNA,31820,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,80.6,Other,Not Seperately Reimbusable,,,,93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.8,Other,Not Seperately Reimbusable,,,,74.4,Other,Not Seperately Reimbusable,,,,25.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.3,Other,Not Seperately Reimbusable,,,,24.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
HEAVY DTY RESTRAINTS,31850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEEL & ELBOW PROT.PR,31900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
HEEL PROTECT(EA)-FULL FOOT,31925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
GLUCOMETER/USE OF (INCLUDES ST,32000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
HOT PACK,32050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
INCONTINENT BRIEF 10,32154,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,125.32,Other,Not Seperately Reimbusable,,,,144.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.56,Other,Not Seperately Reimbusable,,,,115.68,Other,Not Seperately Reimbusable,,,,39.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.33,Other,Not Seperately Reimbusable,,,,38.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
INC PADS-ST HEAVY,32182,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
INC PADS-NIGHTTIME,32184,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
INC PANTS-MED,32186,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
INC PANTS-LG,32188,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
INFANT FORMULA 3 OZ.,32192,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
INFANT FORMULA 6 OZ.,32194,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
INFLATABLE INV. RING,32200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
IRRIGATING LENS,32225,CDM,270,RC,,,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
IRRIGATION TRAY W/5CC BULB,32230,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
K-PAD DISPOSABLE,32250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
KETO DIASTIX H/H,32310,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
LAPIDUS PAD DISPO,32322,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
LEMON&GLYC.SWABS PKG,32350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
LIMB-HOLDER DISP.,32400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,35.36,Other,Not Seperately Reimbusable,,,,40.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.88,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,11.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.1,Other,Not Seperately Reimbusable,,,,10.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
LIMB HOLDER-USE OF,32405,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
CATH LG STPS USE OF,32415,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
CATH SECURE,32430,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
LUBE JELLY,32450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
LUBE JELLY-PACKETS,32460,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,23.92,Other,Not Seperately Reimbusable,,,,27.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,22.08,Other,Not Seperately Reimbusable,,,,7.5,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.5,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
LUBE JELLY-2OZ TUBE,32470,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
LUBE JELLY-5GR. TUBE,32480,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,248.04,Other,Not Seperately Reimbusable,,,,286.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,76.32,Other,Not Seperately Reimbusable,,,,228.96,Other,Not Seperately Reimbusable,,,,77.85,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,77.85,Other,Not Seperately Reimbusable,,,,76.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,76.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
LUMBAR HEAT PACK,32488,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
LUBRICATH LATEX FOLEY CATH-16F,32490,CDM,270,RC,,,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,37.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,30,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,10.2,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.2,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,10,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,38,
MASSAGE LOTION,32500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
MATTRESS-FOAM LEVEL.,32550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
MEMBRANE (AMNI) HOOK,32650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
MICROFEATHER,32654,CDM,270,RC,Y7506,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
MITTEN RESTRA-USE OF,32657,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
MOISTURE BARRIER,32690,CDM,270,RC,A9900,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
MOUTHWASH,32700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
NEONATAL MASK,32725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,286,Other,Not Seperately Reimbusable,,,,330,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,264,Other,Not Seperately Reimbusable,,,,89.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,89.76,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
NOZ-STOP KIT,32850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,286,Other,Not Seperately Reimbusable,,,,330,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,264,Other,Not Seperately Reimbusable,,,,89.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,89.76,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
NURSING PADS,32930,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,68.64,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,63.36,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.54,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PACIFIER,32985,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PAMPERS-MEDIUM,33000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
PAMPERS-SMALL,33050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
RADIAL HOT FORCEPS,33085,CDM,270,RC,Y7506,HCPCS,Outpatient,,,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
PAMPERS-OVERNIGHT,33100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
PAMPERS-PREMATURE,33150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
PERICARE ACUDYNE,33250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PERSONAL BAG,33275,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
PESSARY GYNAFOLD DN.,33300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
PIC LINE REPAIR KIT,33330,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
PLASTER BNDG ORTHFLX,33345,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
PLASTIC NURSERS,33350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,146.12,Other,Not Seperately Reimbusable,,,,168.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,44.96,Other,Not Seperately Reimbusable,,,,134.88,Other,Not Seperately Reimbusable,,,,45.86,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,45.86,Other,Not Seperately Reimbusable,,,,44.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,44.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
POCKET FACE MASK,33380,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
POSEY BELTS-USE OF,33400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PROSHIELDS,33450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RADIAL PEC ART CATH,33490,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
RAPE EVIDENCE KIT,33500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
RAZOR-DISPOSABLE,33550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
RESTON FOAM PAD,33650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
RESTING HAND MITT,33675,CDM,270,RC,Y7506,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
RESUSCITUBE,33700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
ROOM DEODORANT LIQ.,33750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SALINE FLUSH SYRINGE 10ML,33795,CDM,270,RC,,,Outpatient,10,ML,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,3.12,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,3.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,2.88,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
SALINE 9% 100ML,33800,CDM,270,RC,Y7506,HCPCS,Outpatient,100,ML,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
"SCULTETIS BIND,USEOF",33950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SCULTETIS BIND.THOME,34000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SITZ BATH-DISP,34050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SLEEVE FOR S.C.D.,34070,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
SURGI-BRA,34106,CDM,270,RC,Y7506,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
SODIUM CHLORIDE 0.9% 30CC,34108,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SPECIMEN MEASURE/HAT,34111,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
SPEED SPLINT-TRACTION,34115,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
SPIKE PUMP SET,34130,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
SUCROSE,34140,CDM,270,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
SQUIRT BOTTLES,34200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
"SUSPENSORY W LEG STRAPS, LARGE",34350,CDM,270,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
SUSPENSORY W/ LEG STRAP XLARGE,34351,CDM,270,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
SUSTACAL,34360,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TAMPON,34400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
THERMOMETER-ORAL,34450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
THERMOMETER-RECTAL,34500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
THERMOMETER-COV-ORAL,34550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
THERMOMETER-COV-REC,34600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
UMBILICAL TAPE-STRL.,34750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
UNDERPADS/6,34800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
URETH CATH KIT-DISP,34830,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,138.02,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
URINALS,34850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,138.02,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
URINE DRAINAGE BAG HOLDER,34855,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
URINARY DRAIN BAG-CLOSED SYSTE,34860,CDM,270,RC,,,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,18.2,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,21,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,16.8,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,5.71,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.71,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.6,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.6,21.28,
VENIPUNCTURE KIT-NDL,34875,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
VENIPUNC. KIT-VACUT,34880,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
WATER SOLUBLE BAGS,34950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
WOUND CLEANSER 20ML,34980,CDM,270,RC,Y7506,HCPCS,Outpatient,20,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
WOUND CLEANSER PHMB 8OZ,34981,CDM,270,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
CONSOL,35250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,25.54,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
BI-MANUAL VAG.EX.PEL,35700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CATHETERIZATION,35750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
CATHETER-SUPERPUBIC,35800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CUTDOWN PROCEDURE,35850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
ELECTROCAUTHERY USE,35875,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.68,Other,Not Seperately Reimbusable,,,,35.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,28.32,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
ESOPHAGOSCOPE-USE OF,35880,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
CYTOSCOPE-USE OF,35900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,99.84,Other,Not Seperately Reimbusable,,,,115.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,92.16,Other,Not Seperately Reimbusable,,,,31.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.34,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
GASTROSCOPE - USE OF,35925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,48.88,Other,Not Seperately Reimbusable,,,,56.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,45.12,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.34,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
GYN ROOM CHG PELVIC,35950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
FIBER OPTIC MICROSCOPE-USE OF,35975,CDM,270,RC,Y7506,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
INTERCATH-INSERTION,36000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,85.8,Other,Not Seperately Reimbusable,,,,99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
LAPRAOSCOPY,36050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
LASER CAPSULOTOMY,36060,CDM,270,RC,Y7506,HCPCS,Outpatient,,,666,466.2,,,,,,Other,Not Seperately Reimbusable,452.88,68,,362.3,Percent of Total Billed Charges,68% of Total Billed Charges,506.16,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,333,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333,506.16,
LASER FIBER,36065,CDM,270,RC,Y7509,HCPCS,Outpatient,,,980,686,,,,,,Other,Not Seperately Reimbusable,666.4,68,,533.12,Percent of Total Billed Charges,68% of Total Billed Charges,744.8,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,490,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,490,744.8,
LATEX EXTENSION TUBE W/CONNECT,36070,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
OR MICROSCOPE-USE OF,36075,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
DISP PUMP CASSETTE,36085,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
DISPOSABLE ENDOSCOPE VALVE SET,36090,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1833.73,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,1206.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
SIGMOIDOSTOMY,36100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
LITHOTRIPSY-USE OF,36120,CDM,270,RC,Y7506,HCPCS,Outpatient,,,2145,1501.5,,,,,,Other,Not Seperately Reimbusable,1458.6,68,,1166.88,Percent of Total Billed Charges,68% of Total Billed Charges,1630.2,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1072.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,45.24,Other,Not Seperately Reimbusable,,,,52.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,41.76,Other,Not Seperately Reimbusable,,,,14.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.2,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1072.5,1630.2,
URETHAL DILA/SUP/COX,36150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
FILIFORM CATH 24FR,36151,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
FILIFORM CATH 4FR,36152,CDM,270,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
FILFRM CATH 5FR SPRL,36153,CDM,270,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
FILFRM CATH 6FR SPRL,36154,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
RESECTOSCOPE USE OF,36160,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
VITRECTOR,36161,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.56,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,13.44,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
VACUUM DELIVERY CUP,36168,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
YAG LASER,36200,CDM,270,RC,66821,HCPCS,Outpatient,,,400,280,SG,317.62,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,565.28,200,,7.8,Fee Schedule,200% of CMS OPPS Rate,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,709.71,135,,7.2,Fee Schedule,135% of CMS OPPS Rate,,,,2.45,Other,Not Seperately Reimbusable,525.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,525.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,525.71,100,,,Fee Schedule,100% of CMS OPPS Rate,200,709.71,
RENTALS-BED BOARD,37150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
RENTALS-BUCKS TRACT.,37200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RENT.CER.IN-BD.,37250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RENT.CER.IN-BD.W/OHF,37300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RENTALS-CRUTCH,37350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
RENTALS-FOOTBOARD,37400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RENT.FULL BED CRADLE,37450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RENT.O.H.FRAME W/TRP,37500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RENT.PELVIC IN-BED,37550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
RENT.PELV.IN-BD.W/OH,37600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
RENT.TRACTION P/DAY,37631,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
RENT.WALKER PER DAY,37650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ACCU-CHEK/USE OF,37825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ANESTHESIA VENTILATR,37834,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
AV IMPULSE FOOT PAD,37840,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
BILIRUBIN LIGHT P/HR,37850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BRONCHOSCOPE-USE OF,37900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
C-ARM MONITORING,37920,CDM,270,RC,Y7509,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
CO-2 MONITOR-USE OF,37925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
CARDIAC MONITOR,37950,CDM,270,RC,A9900,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,36.92,Other,Not Seperately Reimbusable,,,,42.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,34.08,Other,Not Seperately Reimbusable,,,,11.58,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.58,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
CARPAL TUNNEL TRAY,37960,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
CRASH CART,38000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
DEFIBRILLATOR P/USE,38050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
DENTAL MACHINE,38100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
DERMATONE MACHINE,38110,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
ESOPHAGEAL PROBE,38125,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1017.79,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,669.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ESOPH PROBE-700 SER.,38126,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,279.68,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
EXTERNAL PACER/USE,38130,CDM,270,RC,Y7506,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,127.68,76,,255.97,Percent of Total Billed Charges,76% of Total Billed Charges,84,50,,168.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,939.12,Other,Not Seperately Reimbusable,,,,1083.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,288.96,Other,Not Seperately Reimbusable,,,,866.88,Other,Not Seperately Reimbusable,,,,294.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,294.74,Other,Not Seperately Reimbusable,,,,288.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,288.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,127.68,
FETAL MONITOR OB,38135,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
FLOTATION PAD,38150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.56,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,13.44,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
HUMIDIFIER-USE OF,38175,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
INVASIVE MONITOR/USE,38180,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ISOLETS .50 PER HOUR,38200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
K-PADS P/DAY,38250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
K-THERMIA BLANKET,38300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
KIDDIE MACHINE P/HR,38350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
LAPIOUS PUMP PER DAY,38376,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
NERVE STIMULATR-ELTO,38386,CDM,270,RC,Y7506,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
NON-INVASIVE MON/USE,38390,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,77.82,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,51.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ORAL SUCTION M.P/DAY,38400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,28.6,Other,Not Seperately Reimbusable,,,,33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
ORTHO-ARTHROSCOP-USE,38405,CDM,270,RC,Y7506,HCPCS,Outpatient,,,201,140.7,,,,,,Other,Not Seperately Reimbusable,136.68,68,,109.34,Percent of Total Billed Charges,68% of Total Billed Charges,152.76,76,,176.93,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,116.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.5,152.76,
OXIMETER-USE OF,38410,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,46,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
OXYGEN ANALYZER,38415,CDM,270,RC,A9900,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1666.53,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,1096.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PHACO HYDROS-USE OF,38430,CDM,270,RC,Y7506,HCPCS,Outpatient,,,201,140.7,,,,,,Other,Not Seperately Reimbusable,136.68,68,,109.34,Percent of Total Billed Charges,68% of Total Billed Charges,152.76,76,,655.42,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,431.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.5,152.76,
SEQ COMP DEVICE/DAY,38442,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.08,Other,Not Seperately Reimbusable,,,,17.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
STITCH LAMP W/PERI-C,38450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,42.12,Other,Not Seperately Reimbusable,,,,48.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,38.88,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.22,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SUCTION CURRETTE MCH,38500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,769.12,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,506,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.24,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
TEMP MONITOR,38515,CDM,270,RC,A9900,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
THORATC PUMP,38550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,117.95,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,77.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
TYMPA PROBE,38565,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
VITAL SIGNS,38585,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
WAGENSTEIN SUCTION,38600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
CANE-ADJUSTABLE,38800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
CRUTCH ALUMINUM - ADULT,38850,CDM,270,RC,,,Outpatient,,,23,16.1,,,,,,Other,Not Seperately Reimbusable,15.64,68,,12.51,Percent of Total Billed Charges,68% of Total Billed Charges,17.48,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,11.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.95,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,17.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,4.69,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.69,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,17.48,
CRUTCHES-ADULT-WOOD,38900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,416,Other,Not Seperately Reimbusable,,,,480,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,128,Other,Not Seperately Reimbusable,,,,384,Other,Not Seperately Reimbusable,,,,130.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,130.56,Other,Not Seperately Reimbusable,,,,128,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,128,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
CRUTCHES-PEDI.ALUM.,38950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
CRUTCHES-PEDI.WOOD,39000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
CRUTCH ALUMINUM - YOUTH,39050,CDM,270,RC,,,Outpatient,,,23,16.1,,,,,,Other,Not Seperately Reimbusable,15.64,68,,12.51,Percent of Total Billed Charges,68% of Total Billed Charges,17.48,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,11.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,14.95,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,17.25,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,13.8,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.69,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.69,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.6,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.6,17.48,
CRUTCH ALUMINUM - ADULT (TALL),39051,CDM,270,RC,,,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
CRUTCHES-YOUTH-WOOD,39100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
WALKER-COLLAPS-ALUM,39150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,220,154,,,,,,Other,Not Seperately Reimbusable,149.6,68,,119.68,Percent of Total Billed Charges,68% of Total Billed Charges,167.2,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,110,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,167.2,
ENEMA-FLEETS-ADULT,39400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,186.16,Other,Not Seperately Reimbusable,,,,214.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.28,Other,Not Seperately Reimbusable,,,,171.84,Other,Not Seperately Reimbusable,,,,58.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,58.42,Other,Not Seperately Reimbusable,,,,57.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ENEMA-FLEETS-PEDS.,39450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ENEMA SET-MIN. OIL,39500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ENEMA SET -SS,39550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,718.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,472.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
INSULIN SYRINGE 1CC/BOX 100,39580,CDM,270,RC,,,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
INSULIN SYRINGE-SAFETY-10CC/BO,39585,CDM,270,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
INTAKE-OUTPUT CONT.,39600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SPEC. CONTAINER 24HR,39700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SPUTUM CUP,39850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
UNDERWATER DRAIN BTL,39950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,588.54,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,387.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
VAGINAL IRRIGATOR ST,40000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,26.52,Other,Not Seperately Reimbusable,,,,30.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
BACK PAD,40850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DEFIBRILLATION PADS,41050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SAO2 SENSOR-ADULT,41120,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SAO2 SENSOR-PED,41125,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
MONITORING PADS,41151,CDM,270,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
NERVE STIMU.ELECTRO.,41163,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
INFANT ELECTRODES-PK,41200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SCALP ELECTRO. FETAL,41250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SENSOR/CATH TIP-OB,41270,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,563.62,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,370.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
STERILE ELECTRODES,41300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ABDOMINAL BINDER  SM,48913,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ABDOMINAL BINDER MED,48914,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,119.17,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,78.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,39,Other,Not Seperately Reimbusable,,,,45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ABDOMINAL BINDER  LG,48915,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ABDOMINAL BINDER XL,48917,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,70,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ABDOMINAL BINDER XXL,48918,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ABDUCTION PILLOW,48921,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
ACRIOMIOCLAVICUL.BRC,48950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
ACRIMIOCLAV.SPLT=LG,49000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
ACRIOMIOCLAV.SPLT-SM,49050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
AIRPLANE SPLINT,49100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,253,177.1,,,,,,Other,Not Seperately Reimbusable,172.04,68,,137.63,Percent of Total Billed Charges,68% of Total Billed Charges,192.28,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,126.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,36.92,Other,Not Seperately Reimbusable,,,,42.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,34.08,Other,Not Seperately Reimbusable,,,,11.58,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.58,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.5,192.28,
ANKLE SUPPORT-LARGE,49150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ANKLE SUPPORT-MED.,49200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,175.1,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,115.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ANKLE SUPPORT-SMALL,49250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ANKLE SUPPORT-X-LG,49300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,183.04,Other,Not Seperately Reimbusable,,,,211.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.32,Other,Not Seperately Reimbusable,,,,168.96,Other,Not Seperately Reimbusable,,,,57.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.45,Other,Not Seperately Reimbusable,,,,56.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ANKLE SUPP-OPEN HEEL,49325,CDM,270,RC,Y7508,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ARM-HANG-CAST SLG-LG,49350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
ARM SLING-LG-COMFORT,49400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ARM SLING-MD-COMFORT,49450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ARM SLING-SM-COMFORT,49500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ARM SLING HOSP. MADE,49550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ARM SLING UNIV ADULT,49591,CDM,270,RC,Y7508,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,178.14,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
ARM SLING-VELPEAU-LG,49600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ARM SLING-VELPEAU-MD,49650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ARM SLING-VELPEAU-SM,49700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
ARM SPNT. EXT. METAL,49750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
BANJO SPLINT-ADULT,49800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,105.18,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
BUCKS TRACTION SPLNT,49825,CDM,270,RC,Y7508,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
CAST SHOE XLG,49836,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,215.84,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CHAIR BACK BRACE LG,49841,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
CHAIR BACK BRACE MD,49842,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
CHAIR BACK BRACE SM,49843,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
CLAVICLE BRACE,49850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
CLAV.STRAP-MEEK-SM,49900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CHLORHEXIDINE GLUCONATE 2% CLO,49945,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
CLAV.STRAP-MEEK-X SM,49950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
COCK-UP SPLINT LACED,50000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
COCK-UP SPLINT LARGE,50050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,35.88,Other,Not Seperately Reimbusable,,,,41.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.04,Other,Not Seperately Reimbusable,,,,33.12,Other,Not Seperately Reimbusable,,,,11.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.26,Other,Not Seperately Reimbusable,,,,11.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
COCK-UP SPLINT MED.,50100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
COCK-UP SPLINT SMALL,50150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
COLLAR CERV FOAM LG,50194,CDM,270,RC,Y7508,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
COLLAR-CERV.-FOAM-MD,50200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
COLLAR-CERV.-FOAM-SM,50250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
COLLAR-CERV.-HARD-LG,50300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
COLLAR-TOTAL,50350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
COLLES SPLINT-LARGE,50400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,65.52,Other,Not Seperately Reimbusable,,,,75.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.16,Other,Not Seperately Reimbusable,,,,60.48,Other,Not Seperately Reimbusable,,,,20.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.56,Other,Not Seperately Reimbusable,,,,20.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
COLLES SPLINT-MEDIUM,50450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,61.36,Other,Not Seperately Reimbusable,,,,70.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,56.64,Other,Not Seperately Reimbusable,,,,19.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.26,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
COLLES SPLINT-SMALL,50500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
DUNLOPS TRACT BLT LG,50518,CDM,270,RC,Y7508,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,234.52,Other,Not Seperately Reimbusable,,,,270.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,72.16,Other,Not Seperately Reimbusable,,,,216.48,Other,Not Seperately Reimbusable,,,,73.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,73.6,Other,Not Seperately Reimbusable,,,,72.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,72.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
DUNLOPS TRACT BLT MD,50520,CDM,270,RC,Y7508,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
DUNLOPS TRACT BLT SM,50522,CDM,270,RC,Y7508,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
ELBOW SPLINT-1NF.,50550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
ELBOW SPLINT LG,50554,CDM,270,RC,Y7508,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
ELBOW SPLINT MED,50557,CDM,270,RC,Y7508,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ELBOW SPLINT SM,50560,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.16,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,27.84,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
FINGER SPNT.ALUMINUM,50600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
FINGER SPNT.BASEBALL,50650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1084.72,Other,Not Seperately Reimbusable,,,,1251.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,333.76,Other,Not Seperately Reimbusable,,,,1001.28,Other,Not Seperately Reimbusable,,,,340.43,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,340.43,Other,Not Seperately Reimbusable,,,,333.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,333.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
FINGER SPNT.BURNHAM,50700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
FIN.SPNT.BURNHAM-THB,50750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
FIN.SPNT.FREDDIE FRG,50800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
FIN.SPNT-LEWIN-ST-TB,50850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
FIN.SPNT-LEWIN-STERN,50900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
FIN.SPNT-OTHER,50950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
FINGER SPNT.PROTECTOR,51000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FINGER FLEX GLV S-MR,51001,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
FINGER FLEX GLV S-ML,51002,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
FINGER FLEX GLV L-XR,51003,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
FINGER FLEX GLV L-XL,51004,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
FINGER SPLINT THMBL,51011,CDM,270,RC,Y7508,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
FINGER EXTENSION (SPRING) SPLI,51020,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
FINGER TIP SPLINT,51031,CDM,270,RC,Y7508,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
F/ARM METCRL.SP.L-LG,51050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.L-MD,51100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,61.36,Other,Not Seperately Reimbusable,,,,70.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,56.64,Other,Not Seperately Reimbusable,,,,19.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.26,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.L-SM,51150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.L-XS,51200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.R-LG,51250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.R-MD,51300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,40.04,Other,Not Seperately Reimbusable,,,,46.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.32,Other,Not Seperately Reimbusable,,,,36.96,Other,Not Seperately Reimbusable,,,,12.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.57,Other,Not Seperately Reimbusable,,,,12.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.R-SM,51350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.24,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM METCRL.SP.R-XS,51400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,39,Other,Not Seperately Reimbusable,,,,45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
F/ARM SPLINT LF INF,51443,CDM,270,RC,Y7508,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
F/ARM SPLINT-LEFT-LG,51450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/ARM SPLINT-LEFT-MD,51500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/ARM SPLINT-LEFT-SM,51550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/ARM SPLINT RT INF,51564,CDM,270,RC,Y7508,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,28.6,Other,Not Seperately Reimbusable,,,,33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
F/ARM SPLINT-RGHT-LG,51600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/ARM SPLINT-RGHT-MD,51650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/ARM SPLINT-RGHT-SM,51700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
F/MAN DORSO-LUM.MALE,51750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,229.82,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,151.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
HAND SPNT-FULL-LT-LG,51800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HAND SPNT-FULL-LT-MD,51850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,62.4,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,57.6,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HAND SPNT-FULL-LT-SM,51900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HAND SPNT-FULL-RT-LG,51950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HAND SPNT-FULL-RT-MD,52000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HAND SPNT-FULL-RT-SM,52050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,753.31,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,495.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEAD BLOCK,52065,CDM,270,RC,Y7508,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
HEAD HALTER-DISPO,52075,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1052.45,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,692.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HEAD HALTER-USE OF,52078,CDM,270,RC,Y7508,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.44,Other,Not Seperately Reimbusable,,,,28.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,22.56,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.67,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
HEAVY CLAV.STRAP-LG,52100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEAVY CLAV.STRAP-MD,52150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEAVY CLAV.STRAP-SM,52200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,113.09,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEAVY CLAV.STRAP-XSM,52250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
HEAVY CLAV.STRAP-XXS,52300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
KNEE BRACE HIN/LACED,52350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,48.64,
KNEE HINGE-CAST,52359,CDM,270,RC,Y7508,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
KNEE IMMOBIL-F02M LG,52364,CDM,270,RC,Y7508,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
KNEE IMMOBIL-F02M MD,52366,CDM,270,RC,Y7508,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,504.64,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,332,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.28,Other,Not Seperately Reimbusable,,,,38.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
KNEE IMMOBIL-F02M 5M,52368,CDM,270,RC,Y7508,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,251.71,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,165.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
KNEE IMMOBIL.POST-OP,52400,CDM,270,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,752.7,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,495.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
KNEE SUPPORT-LARGE,52450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,79.04,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
KNEE SUPPORT-MEDIUM,52500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
KNEE SUPPORT-SMALL,52550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.24,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
KNUCKLE BENDER SML,52563,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
KNUCKLE BENDER MED,52564,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
KNUCKLE BENDER LG,52565,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
LUMBO SACRAL BELT-LG,52600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,51.07,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.68,Other,Not Seperately Reimbusable,,,,35.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,28.32,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
LUMBO SACRAL BELT-MD,52650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,83.2,Other,Not Seperately Reimbusable,,,,96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,76.8,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
LUMBO SACRAL BLT SM,52667,CDM,270,RC,Y7508,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,583.07,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,383.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,101.92,Other,Not Seperately Reimbusable,,,,117.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.36,Other,Not Seperately Reimbusable,,,,94.08,Other,Not Seperately Reimbusable,,,,31.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.98,Other,Not Seperately Reimbusable,,,,31.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
LUMBO SACRAL BELT-XL,52700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,83.2,Other,Not Seperately Reimbusable,,,,96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,76.8,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
LUMBO SACRAL BLT XXL,52730,CDM,270,RC,Y7508,HCPCS,Outpatient,,,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
LUMBO SACRAL BRAC.LG,52750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
LUMBO SACRAL BRAC.MD,52800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
LUMBO SACRAL TRACT,52820,CDM,270,RC,Y7508,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
MASON ALLEN SPNT-LG,52850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
MASON ALLEN SPNT-SM,52900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.24,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
METCRPL SPLNT-LT-LRG,52950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.6,Other,Not Seperately Reimbusable,,,,18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
METCRPL SPLNT-LT-MED,53000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,160.51,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,105.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,31.2,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,9.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.79,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
METCRPL SPLNT-LT-SML,53050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,485.79,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,319.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,51.48,Other,Not Seperately Reimbusable,,,,59.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,47.52,Other,Not Seperately Reimbusable,,,,16.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.16,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
METCRPL SPLNT-RT-LRG,53100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,243.81,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,160.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,123.76,Other,Not Seperately Reimbusable,,,,142.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.08,Other,Not Seperately Reimbusable,,,,114.24,Other,Not Seperately Reimbusable,,,,38.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.84,Other,Not Seperately Reimbusable,,,,38.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
METCRPL SPLNT-RT-MED,53150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,140.45,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,92.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,46.28,Other,Not Seperately Reimbusable,,,,53.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.24,Other,Not Seperately Reimbusable,,,,42.72,Other,Not Seperately Reimbusable,,,,14.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.53,Other,Not Seperately Reimbusable,,,,14.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
METCRPL SPLNT-RT-SML,53200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.24,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
NASAL SPLINT,53250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PADDED BOARD SPLINT,53275,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,130.11,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,85.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
PATELLA SPLINT-LARGE,53300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,54.08,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,49.92,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
PATELLA SPLINT-MED.,53350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,117.95,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,77.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
PATELLA SPLINT-SMALL,53400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
PHILADELPA COLLAR SM,53418,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
PHILADELPA COLLR MED,53420,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
PHILADELPA COLLAR LG,53422,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
POST.TIBIA/FIB.ST.LG,53450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
POST.TIBIA/FIB.ST.MD,53500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,65,Other,Not Seperately Reimbusable,,,,75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
POST.TIBIA/FIB.ST.SM,53550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,2766.4,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,1820,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
RIB BELTS 6-MEN-LRG,53600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,967.94,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,636.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-MEN-MED,53650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-MEN-SML.,53700,CDM,270,RC,Y7508,HCPCS,Outpatient,6,ML,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,967.94,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,636.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.08,Other,Not Seperately Reimbusable,,,,17.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-MEN-XLG.,53750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-MEN-XXLG,53800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,458.43,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,301.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-WMN-LRG.,53850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-WMN-MED.,53900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-WMN-SML.,53950,CDM,270,RC,Y7508,HCPCS,Outpatient,6,ML,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-WMN-XLG.,54000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 6-WMN-XXLG,54050,CDM,270,RC,Y7508,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
RIB BELTS 10 MEN,54100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,78,Other,Not Seperately Reimbusable,,,,90,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
RIB BELTS 10 WOMEN,54150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
RING PAD,54159,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
RUSSELL TRACT SLING,54173,CDM,270,RC,Y7508,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
SAM SPLINT,54195,CDM,270,RC,,,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
SHLDR.IMMOBI.MEN-LG,54200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.MEN-MD,54250,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.MEN-SM,54300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.MEN-XLG,54350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.MEN-XXL,54400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,130.11,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,85.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.WMN-LG,54450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,199.42,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,131.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.WMN-MD,54500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.WMN-SM,54550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.WMN-XLG,54600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,65.66,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SHLDR.IMMOBI.WMN-XXL,54650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SKIN-TRAC STRIPS INF,54658,CDM,270,RC,Y7508,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,259.01,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SKIN-TRAC STRIPS ADT,54661,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SLING SET,54676,CDM,270,RC,Y7508,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,86.34,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,56.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
SPLINT-FBRGLS IMMOB,54680,CDM,270,RC,Y7508,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,56.54,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,37.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
THERAPY PUTTY,54686,CDM,270,RC,Y7508,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1029.95,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,677.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
THOMAS LEG SPNT.LRG.,54700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,456.56,Other,Not Seperately Reimbusable,,,,526.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,140.48,Other,Not Seperately Reimbusable,,,,421.44,Other,Not Seperately Reimbusable,,,,143.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,143.29,Other,Not Seperately Reimbusable,,,,140.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,140.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
THOMAS LEG SPNT.-MED,54750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,1422.72,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,936,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
THOMAS LEG SPNT-SML,54800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
THOMAS LEG SPNT 1/2M,54850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,77.22,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
THOMAS LEG SPNT 1/2S,54900,CDM,270,RC,Y7508,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
TIB/FIB-SPL 4TH,54927,CDM,270,RC,Y7508,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
TIB/FIB.SPL.FEMUR LG,54950,CDM,270,RC,Y7508,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
TIB/FIB.SPL.FEMUR MD,55000,CDM,270,RC,Y7508,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,2131.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
"TIB/FIB SPL SM 21""",55100,CDM,270,RC,Y7508,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
"TIB/FIB-SPLINT SM 7""",55109,CDM,270,RC,Y7508,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
TRACTION ANKLET,55121,CDM,270,RC,Y7508,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
UNIVER.TRACTION BELT,55150,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,0.52,Other,Not Seperately Reimbusable,,,,0.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
VISCOPASTE,55157,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
WALKING BOOTS-LARGE,55200,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,5948.67,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3913.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
WALKER MAXTRAX; LARGE,55211,CDM,270,RC,,,Outpatient,,,54,37.8,,,,,,Other,Not Seperately Reimbusable,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,41.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,27,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.1,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,40.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,32.4,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.02,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.02,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.8,41.04,
WALKER MAXTRAX; MEDIUM,55212,CDM,270,RC,,,Outpatient,,,42,29.4,,,,,,Other,Not Seperately Reimbusable,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,31.92,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,21,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.3,65,,36.92,Percent of Total Billed Charges,65% of Total Billed Charges,31.5,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,25.2,60,,34.08,Percent of Total Billed Charges,60% of Total Billed Charges,8.57,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.57,20.4,,11.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.4,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,11.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,31.92,
WALKER MAXTRAX; SMALL,55213,CDM,270,RC,,,Outpatient,,,42,29.4,,,,,,Other,Not Seperately Reimbusable,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,31.92,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,21,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.3,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,31.5,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,25.2,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,8.57,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.57,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.4,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.4,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.4,31.92,
SHOE POST OP FEMALE; SMALL SIZ,55245,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
SHOE POST OP; MALE; MEDIUM LOO,55246,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
SHOE POST OP; MALE; XLARGE LOO,55247,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,138.02,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,10.92,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,12.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,10.08,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,3.42,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,3.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
SHOE POST OP FEMALE; MEDIUM SI,55250,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,111.87,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,73.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
WALKING BOOTS-SMALL,55300,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
WALKING HEELS-ADULT,55350,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
WALKING HEELS-CHILD,55400,CDM,270,RC,Y7508,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
WALKING IRONS,55450,CDM,270,RC,Y7508,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,730.82,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,480.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,129.48,Other,Not Seperately Reimbusable,,,,149.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.84,Other,Not Seperately Reimbusable,,,,119.52,Other,Not Seperately Reimbusable,,,,40.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.64,Other,Not Seperately Reimbusable,,,,39.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
WRIST-F/ARM SP.LT.LG,55500,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,1416.64,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,932,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.LT.MD,55550,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,607.39,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,399.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.16,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,27.84,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.LT.SM,55600,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.LT.XL,55650,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.RT.LG,55700,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,971.58,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,639.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.RT.MD,55750,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,1133.31,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,745.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
WRIST-F/ARM SP.RT.SM,55800,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,324.06,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,213.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ELASTIC WRIST SPLTSM,55813,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ELASTIC WRIST SPLTMD,55814,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
ELASTIC WRIST SPLTLG,55815,CDM,270,RC,Y7508,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1034.82,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.36,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.94,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
UNNA BOOT,55820,CDM,270,RC,,,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,155.65,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.65,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,45.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,36.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,12.44,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.44,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,12.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.2,46.36,
WRIST-F/ARM SP.RT.XL,55850,CDM,270,RC,Y7508,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,510.11,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,335.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
ADHESIVE REMOVER,56010,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,145.31,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,95.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
COLOSTOMY BGS#2 10/P,56050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
COLOSTOMY BGS#3 10/P,56100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
COLOSTOMY RODS,56110,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
CONE/TBE IRRIG.DRAIN,56150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
CONE/TBE IRRIG.SET,56200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
DRAIN CLAMP,56250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
UROSTOMY DRAIN TUBE,56275,CDM,270,RC,Y7506,HCPCS,Outpatient,,,96,67.2,,,,,,Other,Not Seperately Reimbusable,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
DRAINABLE STOMA/MICP,56300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
HOLLISTER ACCESS CLP,56350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
IRRIGATION STRTR.STS,56400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
KARAYA BLANKET - EA.,56450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
KARAYA PASTE,56500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,210.98,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,138.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
KARAYA POWDER - EA.,56550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
KARAYA SEAL RINGS,56585,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
KAR.SEAL ST.B.BX REG,56600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
KARAYA/STOMA/MICROP.,56650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,68.12,Other,Not Seperately Reimbusable,,,,78.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.96,Other,Not Seperately Reimbusable,,,,62.88,Other,Not Seperately Reimbusable,,,,21.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.38,Other,Not Seperately Reimbusable,,,,20.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
LOOP OSTOMY BRDGE.EA,56700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
LOOP OSTOMY DRAIN.EA,56750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,63.23,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
LOOP OSTOMY GSKT. EA,56800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
OSTOMY BELTS,56850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PERINEAL WASH P2008,56900,CDM,270,RC,,,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
SKIN GEL,56935,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,62.62,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
STERILE PCKD DRN SET,56950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,885.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,582.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
STOMA COVER,56990,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
STOMA IRRIG. DRAIN,57000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
STOMA LUBE,57020,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
STOMA PASTE,57030,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,347.78,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,228.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
STOMAHESIVE 4X4,57050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,608.61,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,400.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
STOMAHESIVE 8X8,57100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,1375.9,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,905.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
STOMA/MICROPORE/FLTR,57150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
UROSTOMY BAGS-MED,57200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
UROSTOMY BAGS-SHORT,57250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,5149.76,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,3388,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
FILTER SECURITY BAGS,57261,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,894.98,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,588.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,22.36,Other,Not Seperately Reimbusable,,,,25.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,20.64,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
AB KIT,57410,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1674,1171.8,,,,,,Other,Not Seperately Reimbusable,1138.32,68,,910.66,Percent of Total Billed Charges,68% of Total Billed Charges,1272.24,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,837,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,837,1272.24,
ACU CLIP RT ANGLE,57415,CDM,270,RC,Y7509,HCPCS,Outpatient,,,421,294.7,,,,,,Other,Not Seperately Reimbusable,286.28,68,,229.02,Percent of Total Billed Charges,68% of Total Billed Charges,319.96,76,,196.38,Percent of Total Billed Charges,76% of Total Billed Charges,210.5,50,,129.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.5,319.96,
ADAPTER PIN-UNIVERSAL #1701548,57420,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,12.48,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.92,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
AIRWAY 40 MM,57425,CDM,270,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,27.04,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,31.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,24.96,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,8.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,8.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
AIRWAY 60 MM,57450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AIRWAY 80 MM,57500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,127.92,Other,Not Seperately Reimbusable,,,,147.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,118.08,Other,Not Seperately Reimbusable,,,,40.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.14,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AIRWAY 90 MM,57550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AIRWAY 100 MM,57600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,113.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.24,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AIRWAY 110 MM,57650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AIRWAY-NASAL 34F,57670,CDM,270,RC,Y7509,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
AIRWAY-RESUSITUBE,57675,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
AIRWAY-NASO-PHARYN.,57685,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ALLIGATOR FORCEPS,57690,CDM,270,RC,Y7509,HCPCS,Outpatient,,,128,89.6,,,,,,Other,Not Seperately Reimbusable,87.04,68,,69.63,Percent of Total Billed Charges,68% of Total Billed Charges,97.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,64,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64,97.28,
ANGIOPLASTY CATHETER,57775,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
ANTENNA,57795,CDM,270,RC,Y7509,HCPCS,Outpatient,,,291,203.7,,,,,,Other,Not Seperately Reimbusable,197.88,68,,158.3,Percent of Total Billed Charges,68% of Total Billed Charges,221.16,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,145.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.5,221.16,
ANTENNA ADAPTER,57797,CDM,270,RC,Y7509,HCPCS,Outpatient,,,115,80.5,,,,,,Other,Not Seperately Reimbusable,78.2,68,,62.56,Percent of Total Billed Charges,68% of Total Billed Charges,87.4,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,57.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,81.12,Other,Not Seperately Reimbusable,,,,93.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,74.88,Other,Not Seperately Reimbusable,,,,25.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.46,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.5,87.4,
ANTI-REFLUX PROSTHE.,57800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1078,754.6,,,,,,Other,Not Seperately Reimbusable,733.04,68,,586.43,Percent of Total Billed Charges,68% of Total Billed Charges,819.28,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,539,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,539,819.28,
ANTI-REFLUX VALVE,57803,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
ARTHROSCOPIC DRAPE,57806,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
ATRIAL LEAD,57810,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1265,885.5,,,,,,Other,Not Seperately Reimbusable,860.2,68,,688.16,Percent of Total Billed Charges,68% of Total Billed Charges,961.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,632.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,632.5,961.4,
BAIN CIRCUIT - ANEST,57824,CDM,270,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
BIOPSY FORCEPS,57940,CDM,270,RC,Y7506,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,131.92,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,147.44,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,97,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,147.44,
BIOPSY FORCEPS-SMALL CUP,57943,CDM,270,RC,Y7509,HCPCS,Outpatient,,,117,81.9,,,,,,Other,Not Seperately Reimbusable,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,88.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,58.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.5,88.92,
BIOPSY FORCEP HOT,57945,CDM,270,RC,Y7509,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,89.96,Other,Not Seperately Reimbusable,,,,103.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.68,Other,Not Seperately Reimbusable,,,,83.04,Other,Not Seperately Reimbusable,,,,28.23,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.23,Other,Not Seperately Reimbusable,,,,27.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
BI POLAR LEADS,57950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,119.6,Other,Not Seperately Reimbusable,,,,138,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,110.4,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.54,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
BIFLO NASAL CANNULA,57953,CDM,270,RC,A4615,HCPCS,Outpatient,,,5,3.5,,0.53,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1081.63,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,711.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
BITE BLOCKS,57955,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,302.18,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,198.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BLADE-GIGLI SAW,57965,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,32.83,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
BLADE-ORTHO,57966,CDM,270,RC,Y7506,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,79.04,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
BLADE-MICRO SAW 4.5MM X 25.5MM,57967,CDM,270,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,51.07,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
BLADE-ISOLATING SAW,57968,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,158.69,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
BLADE-SINGLE USE FOR CLIPPER,57969,CDM,270,RC,Y7509,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
BLADE-TOME,57970,CDM,270,RC,Y7506,HCPCS,Outpatient,,,181,126.7,,,,,,Other,Not Seperately Reimbusable,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,137.56,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.5,137.56,
OSCILLATOR BLADE,57971,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
BLOOD PR. CUFF-DISP.,57975,CDM,270,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,22.36,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,25.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
BLOOD PLUMSET Y-TYPE 110IN 200,57978,CDM,270,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
"BLOOD WRMR.CUFFS,DIS",57982,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,58.76,Other,Not Seperately Reimbusable,,,,67.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.08,Other,Not Seperately Reimbusable,,,,54.24,Other,Not Seperately Reimbusable,,,,18.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.44,Other,Not Seperately Reimbusable,,,,18.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
BLUNTPORT 5-12MM,57985,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
BONE CEMENT,57991,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,1043.33,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,686.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
BONE SCREW,58000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,84.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
BONE SURGICAL TRAY,58025,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1181,826.7,,,,,,Other,Not Seperately Reimbusable,803.08,68,,642.46,Percent of Total Billed Charges,68% of Total Billed Charges,897.56,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,590.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,590.5,897.56,
BONE WAX,58050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
BOOTS,58100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BOVIE CAU PEN W/HSWT,58150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.24,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.96,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
BOVIE TIP,58175,CDM,270,RC,Y7506,HCPCS,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
BOVIE CORD-DISP,58200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,283.94,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,186.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
BUTTON,58210,CDM,270,RC,A4555,HCPCS,Outpatient,,,968,677.6,,8.82,100,,,fee schedule,100% Aetna Market fee schedule,658.24,68,,526.59,Percent of Total Billed Charges,68% of Total Billed Charges,735.68,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,484,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484,735.68,
CAROTID ARTERY SHUNT,58225,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1571.68,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,1034,Percent of Total Billed Charges,50% of Total Billed Charges,,,,117,Other,Not Seperately Reimbusable,,,,135,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,108,Other,Not Seperately Reimbusable,,,,36.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36.72,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ORTHO BURR,58238,CDM,270,RC,Y7506,HCPCS,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,1400.22,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,921.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
CASSETTE DRAPE,58250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,2393.09,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,1574.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
CATHETER INTRAUTER,58294,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,526.53,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,346.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
CATHETER INTRODUCER,58300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CATH INTRODUCER TRAY,58305,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
CAUT/FT CTRL SUCTION,58308,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,88.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,58.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CAUTERY/DISPOSABLE,58310,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
CAUTERY SUCTION,58315,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,735.07,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,483.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
CEMENT MIXING BOWL,58318,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,880.38,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,579.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
CEMENT MIXING KIT II,58320,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,980.7,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,645.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
CENT VENOUS CATH KIT,58325,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,127.92,Other,Not Seperately Reimbusable,,,,147.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,118.08,Other,Not Seperately Reimbusable,,,,40.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.14,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
CIDEX SOAK,58327,CDM,270,RC,A9900,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,150.18,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
CLAVE CONNECTOR,58328,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
CONFORMER/EACH,58330,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
COOK S/P KIT,58335,CDM,270,RC,Y7506,HCPCS,Outpatient,,,175,122.5,,,,,,Other,Not Seperately Reimbusable,119,68,,95.2,Percent of Total Billed Charges,68% of Total Billed Charges,133,76,,878.56,Percent of Total Billed Charges,76% of Total Billed Charges,87.5,50,,578,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.5,133,
CORD DAC ACTIVE DISP,58340,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
CURRETTS-CURVED,58350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,217.66,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,143.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
CURRETTE ENDO SUCT.,58356,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CURRETTS-STRAIGHT,58400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
CYSTO APRON,58450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1084.67,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,713.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
CYSTOTOME 25 GA,58455,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,627.46,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,412.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
CYSTOTOME NEEDLE,58460,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,206.72,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,136,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
CYTOLOGY BRUSH-DISPO,58475,CDM,270,RC,Y7506,HCPCS,Outpatient,,,288,201.6,,,,,,Other,Not Seperately Reimbusable,195.84,68,,156.67,Percent of Total Billed Charges,68% of Total Billed Charges,218.88,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,144,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144,218.88,
DELIVERY ROOM SET-UP,58500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
DERMATOME CUTTING HD,58550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DERMATOME BLDS,58600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
DERMATONE GLUE,58650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,60.32,Other,Not Seperately Reimbusable,,,,69.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.56,Other,Not Seperately Reimbusable,,,,55.68,Other,Not Seperately Reimbusable,,,,18.93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.93,Other,Not Seperately Reimbusable,,,,18.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
DERMATONE TAPE-REECE,58700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,190.91,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,125.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
DERMATONE TAPE-STRYR,58750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,728.38,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,479.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
DISCARD-A-PAD,58800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DISPOSABLE CLIP FIXING DEVICE,58825,CDM,270,RC,Y7509,HCPCS,Outpatient,,,112,78.4,,,,,,Other,Not Seperately Reimbusable,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
DOUBLE VELOUR GRAFT,58850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,293,205.1,,,,,,Other,Not Seperately Reimbusable,199.24,68,,159.39,Percent of Total Billed Charges,68% of Total Billed Charges,222.68,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,146.5,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.5,222.68,
DRILLS,58900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
DUOVISC SUPPLY,58910,CDM,270,RC,Y7509,HCPCS,Outpatient,,,172,120.4,,,,,,Other,Not Seperately Reimbusable,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86,130.72,
ELECT VAPORIZATION,58965,CDM,270,RC,Y7506,HCPCS,Outpatient,,,280,196,,,,,,Other,Not Seperately Reimbusable,190.4,68,,152.32,Percent of Total Billed Charges,68% of Total Billed Charges,212.8,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,140,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140,212.8,
ENDOCATH 10MM,58985,CDM,270,RC,Y7506,HCPCS,Outpatient,,,173,121.1,,,,,,Other,Not Seperately Reimbusable,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,300.96,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,198,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.5,131.48,
ENDO BABCOCK,58990,CDM,270,RC,Y7509,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
ENDO GIA30,58995,CDM,270,RC,Y7509,HCPCS,Outpatient,,,355,248.5,,,,,,Other,Not Seperately Reimbusable,241.4,68,,193.12,Percent of Total Billed Charges,68% of Total Billed Charges,269.8,76,,150.18,Percent of Total Billed Charges,76% of Total Billed Charges,177.5,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.5,269.8,
ENDO GIA30 LOADS,58999,CDM,270,RC,Y7509,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,242.59,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.24,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.12,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
ENDOTRACHEAL TBE 2.0,59000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,384.26,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,252.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 2.5,59050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 3.0,59100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 3.5,59150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 4.0,59200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,263.87,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,173.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 4.5,59250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,138.02,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 5.0,59300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 5.5,59316,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,125.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 6.0,59350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,445.66,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,293.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 6.5,59400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,86.34,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,56.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 7.0,59450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 7.5,59500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 8.0,59550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,245.63,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 8.5,59561,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,245.63,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 9.0,59600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,245.63,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 9.5,59615,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,245.63,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDOTRACHEAL TBE 10.,59650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDO MARK-ENDOSCOPIC INK MARKE,59655,CDM,270,RC,,,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.7,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,43.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,34.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,11.83,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.83,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.6,44.08,
ENDOTRACHEAL TB 10.5,59660,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ENDO TUBE-FOME CUF,59661,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,117.95,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,77.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
ENDO TUBE UNCUFD 2.5,59662,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,215.23,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,141.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TRECHEA TUBE 20,59663,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,62.4,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,57.6,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.58,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TUBE UNCUFD 3.5,59664,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,65,Other,Not Seperately Reimbusable,,,,75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TUBE UNCUFD 4.0,59665,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TUBE UNCUFD 4.5,59666,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,81.12,Other,Not Seperately Reimbusable,,,,93.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,74.88,Other,Not Seperately Reimbusable,,,,25.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.46,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 3.0,59670,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 3.5,59673,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 4.5,59676,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 8.0,59684,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 10.0,59688,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,218.88,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,144,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TBE UNCUF 12.0,59692,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TB W/MURPHY EYE,59694,CDM,270,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,51.07,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
ENDO TUBE HOLDER-EA.,59695,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
ENDO TUBE EXCHANGER,59696,CDM,270,RC,Y7509,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
EPIDURAL PACK,59697,CDM,270,RC,A4300,HCPCS,Outpatient,,,49,34.3,,14.82,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
EPIDURAL SET,59698,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
EPIX ALLIED GRASPER,59699,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
ESOPHAGEAL STETHESC.,59700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
COMBITUBE ESO. TREAC,59710,CDM,270,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.16,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,27.84,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
EYE SHIELD,59725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
EYE SPONGES/PKG,59730,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
EYE SURGICAL PACK,59735,CDM,270,RC,Y7509,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,22.88,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,7.18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.18,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
EYE INSTRUMENT SURG TRAY,59740,CDM,270,RC,Y7509,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
C-ARM DRAPE,59750,CDM,270,RC,,,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
EXTERNAL P/MAKER-/HR,59800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
EXTRA INSTR.PER EACH,59850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FACET PACK,59855,CDM,270,RC,Y7506,HCPCS,Outpatient,,,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.5,35.72,
FALOPE RING,59900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
FLUID BLOOD WARMER TUBING,59902,CDM,270,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
FLUID WARMER,59904,CDM,270,RC,Y7509,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
FAST TRACK LMA,59905,CDM,270,RC,Y7509,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
FOAM GEL,59909,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
FOGARTY CATH-2FR,59910,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,178.14,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
FOGARTY CATH-4FR/6FR,59920,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
FORCEP DISP BOX,59925,CDM,270,RC,Y7509,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
FORCEP FOREIGN BODY,59927,CDM,270,RC,Y7509,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
FORCEP-HOT BIOPSY,59930,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
GASTRO FEEDING TUBE 20FR 7-10M,59937,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GASTRO FEEDING TUBE 26FR 20CC,59938,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GASTRO FEEDING TUBE 24FR 22CC,59939,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GASTRO FEEDING TUBE 16FR 3-5ML,59940,CDM,270,RC,,,Outpatient,5,ML,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GASTRO FEEDING TUBE 18FR MIC B,59942,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GROSHONGE KIT,59943,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1239,867.3,,,,,,Other,Not Seperately Reimbusable,842.52,68,,674.02,Percent of Total Billed Charges,68% of Total Billed Charges,941.64,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,619.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619.5,941.64,
GROSHONGE REPAIR KIT,59944,CDM,270,RC,Y7509,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
GORE-TEX DUAL MESH,59945,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1731,1211.7,,,,,,Other,Not Seperately Reimbusable,1177.08,68,,941.66,Percent of Total Billed Charges,68% of Total Billed Charges,1315.56,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,865.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,865.5,1315.56,
GASTRO FEEDING TUBE 22FR 7-10C,59946,CDM,270,RC,,,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.45,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,39.75,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,31.8,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,10.81,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.81,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,10.6,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.6,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10.6,40.28,
GORE-TEX SUTURE,59947,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
GUIDEWIRE-COATED #620-103,59948,CDM,270,RC,Y7509,HCPCS,Outpatient,,,60,42,,,,,,Other,Not Seperately Reimbusable,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,45.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,30,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,45.6,
HAGIE PIN,59950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
GYRUS BUTTERFLY VENT TUBE 1.27,59952,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
GYRUS REUTER-BOBBIN VENT TUBE,59954,CDM,270,RC,,,Outpatient,,,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.45,65,,335.4,Percent of Total Billed Charges,65% of Total Billed Charges,24.75,75,,387,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,19.8,60,,309.6,Percent of Total Billed Charges,60% of Total Billed Charges,6.73,20.4,,105.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.73,20.4,,105.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.6,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.6,20,,103.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.6,25.08,
GYRUS PAPAPELLEA,59956,CDM,270,RC,,,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.5,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,22.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,18,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.12,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.12,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6,22.8,
HARMONIC GEN,59960,CDM,270,RC,,,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,55,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,71.5,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,82.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,66,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,22.44,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.44,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,22,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22,83.6,
HARMONIC,59962,CDM,270,RC,Y7506,HCPCS,Outpatient,,,830,581,,,,,,Other,Not Seperately Reimbusable,564.4,68,,451.52,Percent of Total Billed Charges,68% of Total Billed Charges,630.8,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,415,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415,630.8,
HARMONIC SLEEVE 5MM,59965,CDM,270,RC,,,Outpatient,,,414,289.8,,,,,,Other,Not Seperately Reimbusable,281.52,68,,225.22,Percent of Total Billed Charges,68% of Total Billed Charges,314.64,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,207,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,269.1,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,310.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,248.4,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,84.46,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,84.46,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,82.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.8,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,82.8,314.64,
HARMONIC SHEARS,59967,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1238,866.6,,,,,,Other,Not Seperately Reimbusable,841.84,68,,673.47,Percent of Total Billed Charges,68% of Total Billed Charges,940.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,619,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619,940.88,
HARMONIC CORD,59970,CDM,270,RC,,,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,98.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,84.5,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,78,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,26.52,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,26,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26,98.8,
HANSEN STREET NAILS,60000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
HEAD AND HEEL REST,60025,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
HEAD POSITIONER SLOTTED ADULT,60030,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,251.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HEMATURA CATH,60045,CDM,270,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,148.35,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
HEMOVAC DRAIN 200 ML,60050,CDM,270,RC,Y7506,HCPCS,Outpatient,200,ML,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
HEMOVAC DRAIN 400 ML,60100,CDM,270,RC,Y7506,HCPCS,Outpatient,400,ML,84,58.8,,,,,,Other,Not Seperately Reimbusable,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
HEMOVAC WITH NEEDLE,60150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
HIP PINNING,60190,CDM,270,RC,Y7506,HCPCS,Outpatient,,,959,671.3,,,,,,Other,Not Seperately Reimbusable,652.12,68,,521.7,Percent of Total Billed Charges,68% of Total Billed Charges,728.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,479.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,479.5,728.84,
HIP SPICA-ADULT,60200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,48.64,
HIP SPICA-CHILD,60250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
HOOKED INTRAMED.PINS,60300,CDM,270,RC,A9900,HCPCS,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
HUMID VENT,60375,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HYSTERECTOMY DRN.KIT,60400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
INFUSION SET 20G INJECTABLE,60410,CDM,270,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
INSORB STAPLER,60420,CDM,270,RC,Y7509,HCPCS,Outpatient,,,102,71.4,,,,,,Other,Not Seperately Reimbusable,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
INTRODUCER BOUGIE,60421,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
INTRODUCER KIT,60422,CDM,270,RC,Y7506,HCPCS,Outpatient,,,264,184.8,,,,,,Other,Not Seperately Reimbusable,179.52,68,,143.62,Percent of Total Billed Charges,68% of Total Billed Charges,200.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,132,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132,200.64,
IO NEEDLE,60429,CDM,270,RC,A4212,HCPCS,Outpatient,,,231,161.7,,3.36,100,,,fee schedule,100% Aetna Market fee schedule,157.08,68,,125.66,Percent of Total Billed Charges,68% of Total Billed Charges,175.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,115.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,175.56,
IRRIG IOL POSITIONR,60430,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
JACKSN-PRAT DRN&BULB,60436,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
JEWETTE NAILS,60450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,214,149.8,,,,,,Other,Not Seperately Reimbusable,145.52,68,,116.42,Percent of Total Billed Charges,68% of Total Billed Charges,162.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107,162.64,
JORDAN IMPLANT,60475,CDM,270,RC,Y7506,HCPCS,Outpatient,,,64,44.8,,,,,,Other,Not Seperately Reimbusable,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,48.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,48.64,
KIT-APPENDECTOMY,60555,CDM,270,RC,Y7506,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,131.92,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,147.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,97,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,147.44,
KITTNER ENDO SNGL TP,60600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
KIRSCHNER WIRE,60650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.68,Other,Not Seperately Reimbusable,,,,35.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,28.32,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
KNIFE COLD,60680,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
KNIFE RESECTOSCOPE,60690,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.56,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,13.44,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
KNOWLES PINS,60700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
LAMINARIA,60750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
LEADS-ATRIAL,60760,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1592,1114.4,,,,,,Other,Not Seperately Reimbusable,1082.56,68,,866.05,Percent of Total Billed Charges,68% of Total Billed Charges,1209.92,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,796,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,83.2,Other,Not Seperately Reimbusable,,,,96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,76.8,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.11,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,796,1209.92,
LEADS-TEMPORARY/EA.,60775,CDM,270,RC,Y7506,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
LEADS-VENTRICLE,60780,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1592,1114.4,,,,,,Other,Not Seperately Reimbusable,1082.56,68,,866.05,Percent of Total Billed Charges,68% of Total Billed Charges,1209.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,796,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,82.68,Other,Not Seperately Reimbusable,,,,95.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,76.32,Other,Not Seperately Reimbusable,,,,25.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.95,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,796,1209.92,
LESI PACK,60781,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
LIGASURE LG,60782,CDM,270,RC,Y7506,HCPCS,Outpatient,,,754,527.8,,,,,,Other,Not Seperately Reimbusable,512.72,68,,410.18,Percent of Total Billed Charges,68% of Total Billed Charges,573.04,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,377,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,377,573.04,
LIGHT HANDLES,60783,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
LIGHT SHIELDS,60784,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
LMA SIZE 3-4-5,60785,CDM,270,RC,Y7509,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
LMA UNIQUE SIZE 2.5,60786,CDM,270,RC,Y7509,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
LMA SUPREME SIZE 4,60787,CDM,270,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
LMA SUPREME SIZE 5,60788,CDM,270,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
LOOP COAG,60790,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
LOOP CUTTING,60792,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,111.28,Other,Not Seperately Reimbusable,,,,128.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,34.24,Other,Not Seperately Reimbusable,,,,102.72,Other,Not Seperately Reimbusable,,,,34.93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,34.93,Other,Not Seperately Reimbusable,,,,34.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,34.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
LOTTES TIBIA NAILS,60800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
LUKITUBES 3,60850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
LUKITUBES 61/4,60900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
LTA KIT,60950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
MAMMARY PROSTHESIS,61000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,214,149.8,,,,,,Other,Not Seperately Reimbusable,145.52,68,,116.42,Percent of Total Billed Charges,68% of Total Billed Charges,162.64,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107,162.64,
MARLEX MESH,61050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,328,229.6,,,,,,Other,Not Seperately Reimbusable,223.04,68,,178.43,Percent of Total Billed Charges,68% of Total Billed Charges,249.28,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,164,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164,249.28,
MASK-LARYNGEAL,61110,CDM,270,RC,Y7506,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,86.64,
MAXILLOFACIAL KITS,61135,CDM,270,RC,Y7506,HCPCS,Outpatient,,,108,75.6,,,,,,Other,Not Seperately Reimbusable,73.44,68,,58.75,Percent of Total Billed Charges,68% of Total Billed Charges,82.08,76,,78.43,Percent of Total Billed Charges,76% of Total Billed Charges,54,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.68,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,16.32,Other,Not Seperately Reimbusable,,,,5.55,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.55,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,82.08,
MERCURY,61200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
MESH PLUG,61203,CDM,270,RC,Y7509,HCPCS,Outpatient,,,426,298.2,,,,,,Other,Not Seperately Reimbusable,289.68,68,,231.74,Percent of Total Billed Charges,68% of Total Billed Charges,323.76,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,213,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,460.72,Other,Not Seperately Reimbusable,,,,531.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,141.76,Other,Not Seperately Reimbusable,,,,425.28,Other,Not Seperately Reimbusable,,,,144.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,144.59,Other,Not Seperately Reimbusable,,,,141.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,141.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213,323.76,
MEROCEL PACK,61204,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,75.39,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,49.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.04,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
METZ TIP,61205,CDM,270,RC,Y7509,HCPCS,Outpatient,,,142,99.4,,,,,,Other,Not Seperately Reimbusable,96.56,68,,77.25,Percent of Total Billed Charges,68% of Total Billed Charges,107.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,71,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71,107.92,
MYRINGOTOMY KNIFE,61220,CDM,270,RC,Y7509,HCPCS,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,13.68,
NASO-TAMP/PKG,61225,CDM,270,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
NASAL PACK,61235,CDM,270,RC,Y7509,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,211.12,Other,Not Seperately Reimbusable,,,,243.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,64.96,Other,Not Seperately Reimbusable,,,,194.88,Other,Not Seperately Reimbusable,,,,66.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,66.26,Other,Not Seperately Reimbusable,,,,64.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,64.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
NASAL PACKING - MEDIUM 5X1X2CM,61238,CDM,270,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,282.88,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,326.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,261.12,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,88.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,88.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,87.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
NEEDLE TIP BOVIE,61240,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
O BAND LIGATOR,61265,CDM,270,RC,Y7509,HCPCS,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,117.04,Other,Not Seperately Reimbusable,,,,125.4,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
OPEN END CATH,61267,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,215.04,Other,Not Seperately Reimbusable,,,,230.4,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
OPTH CRESCENT KNIFE,61270,CDM,270,RC,Y7506,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,219.96,Other,Not Seperately Reimbusable,,,,253.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,67.68,Other,Not Seperately Reimbusable,,,,203.04,Other,Not Seperately Reimbusable,,,,69.03,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,69.03,Other,Not Seperately Reimbusable,,,,67.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
OPTH SLIT BLADE,61278,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
OR DENTAL/SCOPE C/CS,61310,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
PACEMAKER,61320,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9784,6848.8,,,,,,Other,Not Seperately Reimbusable,6653.12,68,,5322.5,Percent of Total Billed Charges,68% of Total Billed Charges,7435.84,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4892,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4892,7435.84,
PADS ARM BOARD,61325,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,293.44,Other,Not Seperately Reimbusable,,,,314.4,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PAIN PACK,61327,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,88.4,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,102,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,2.2,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,81.6,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,27.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,27.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
PALL BLOOD FILTER,61330,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,196,Other,Not Seperately Reimbusable,,,,210,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PALL HEAT & MOISTURE,61340,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PANTY-OB MESH,61375,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
PERCUTANEOUS SIL.CAT,61400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
PERCUT SUPRAPUBIC CATHETER SET,61405,CDM,270,RC,Y7509,HCPCS,Outpatient,,,184,128.8,,,,,,Other,Not Seperately Reimbusable,125.12,68,,100.1,Percent of Total Billed Charges,68% of Total Billed Charges,139.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,92,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,187.6,Other,Not Seperately Reimbusable,,,,201,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92,139.84,
PHOTO CHARGE,61410,CDM,270,RC,Y7509,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
PORT ACCESS KIT,61422,CDM,270,RC,Y7509,HCPCS,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.56,Other,Not Seperately Reimbusable,,,,60.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,22.8,
PORT-A-CATH POWER LOC,61423,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1202,841.4,,,,,,Other,Not Seperately Reimbusable,817.36,68,,653.89,Percent of Total Billed Charges,68% of Total Billed Charges,913.52,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,601,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601,913.52,
PERITONEAL VENOUS SH,61425,CDM,270,RC,Y7506,HCPCS,Outpatient,,,999,699.3,,,,,,Other,Not Seperately Reimbusable,679.32,68,,543.46,Percent of Total Billed Charges,68% of Total Billed Charges,759.24,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,499.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.5,759.24,
PORCINE SKIM,61426,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
PLASTIBELL,61427,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.6,Other,Not Seperately Reimbusable,,,,18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
PROSTHESIS-ORTHOPED,61429,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1864,1304.8,,,,,,Other,Not Seperately Reimbusable,1267.52,68,,1014.02,Percent of Total Billed Charges,68% of Total Billed Charges,1416.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,932,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,932,1416.64,
PROSTHESIS-VASC./STR,61430,CDM,270,RC,Y7506,HCPCS,Outpatient,,,533,373.1,,,,,,Other,Not Seperately Reimbusable,362.44,68,,289.95,Percent of Total Billed Charges,68% of Total Billed Charges,405.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,266.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.16,Other,Not Seperately Reimbusable,,,,19.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.38,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.5,405.08,
PROBE-INSULSCAN,61432,CDM,270,RC,Y7506,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,945.6,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
PORT-A-CATH INTRODUCER KIT,61433,CDM,270,RC,Y7509,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,78,Other,Not Seperately Reimbusable,,,,90,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
PROGRAMMER,61434,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1702,1191.4,,,,,,Other,Not Seperately Reimbusable,1157.36,68,,925.89,Percent of Total Billed Charges,68% of Total Billed Charges,1293.52,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,851,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.72,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,851,1293.52,
PROLITE MESH,61435,CDM,270,RC,Y7509,HCPCS,Outpatient,,,256,179.2,,,,,,Other,Not Seperately Reimbusable,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,194.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,128,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128,194.56,
PROSTHESIS-VASC./BI,61440,CDM,270,RC,Y7506,HCPCS,Outpatient,,,839,587.3,,,,,,Other,Not Seperately Reimbusable,570.52,68,,456.42,Percent of Total Billed Charges,68% of Total Billed Charges,637.64,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,419.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,44.72,Other,Not Seperately Reimbusable,,,,51.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,13.76,Other,Not Seperately Reimbusable,,,,41.28,Other,Not Seperately Reimbusable,,,,14.03,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.03,Other,Not Seperately Reimbusable,,,,13.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,419.5,637.64,
PROTECTOR II,61450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
PROBE COVER,61451,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
PULL PEG KIT,61453,CDM,270,RC,Y7509,HCPCS,Outpatient,,,239,167.3,,,,,,Other,Not Seperately Reimbusable,162.52,68,,130.02,Percent of Total Billed Charges,68% of Total Billed Charges,181.64,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,119.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.5,181.64,
PUMP-IV,61475,CDM,270,RC,Y7507,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.68,Other,Not Seperately Reimbusable,,,,35.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,28.32,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.63,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PUMP-IV/CCU,61480,CDM,270,RC,Y7507,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,30.16,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,27.84,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.46,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
PUMP-PCA,61490,CDM,270,RC,Y7507,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,85.8,Other,Not Seperately Reimbusable,,,,99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.93,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
PUSHERS,61500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
RAZOR-STERILE,61510,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
RAZOR BLADE-DISP,61525,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
READYBATH CAP,61545,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.28,Other,Not Seperately Reimbusable,,,,38.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.56,Other,Not Seperately Reimbusable,,,,30.6,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
RECEPTAL VALVES,61600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
REMOVER LOTION 0.5 OZ,61620,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
REMOVER LOTION 4 OZ,61625,CDM,270,RC,Y7509,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
RENAL DILATATION SET,61630,CDM,270,RC,Y7509,HCPCS,Outpatient,,,347,242.9,,,,,,Other,Not Seperately Reimbusable,235.96,68,,188.77,Percent of Total Billed Charges,68% of Total Billed Charges,263.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,173.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.5,263.72,
RESECTOSCOPE LOOPS,61650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
"RETROBULBAR  1 1/2""",61665,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.08,Other,Not Seperately Reimbusable,,,,17.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.74,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
RETROBULBAR NEEDLE,61670,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,26.52,Other,Not Seperately Reimbusable,,,,30.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ROLLER UROLOGY,61672,CDM,270,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.56,Other,Not Seperately Reimbusable,,,,31.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,25.44,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.65,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
RUSCH S/P PUNCTURE,61675,CDM,270,RC,Y7506,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
RUSH ROD,61680,CDM,270,RC,Y7506,HCPCS,Outpatient,,,104,72.8,,,,,,Other,Not Seperately Reimbusable,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,79.04,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52,79.04,
SAT O2 FINGER PROBE,61690,CDM,270,RC,A9900,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,278.88,Other,Not Seperately Reimbusable,,,,298.8,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SCALPEL-DISP. #10,61700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SCALPEL-DISP. #11,61750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SCALPEL-DISP. #15,61800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SCLEROTOME BLADES,61850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,103,72.1,,,,,,Other,Not Seperately Reimbusable,70.04,68,,56.03,Percent of Total Billed Charges,68% of Total Billed Charges,78.28,76,,52.9,Percent of Total Billed Charges,76% of Total Billed Charges,51.5,50,,34.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,118.16,Other,Not Seperately Reimbusable,,,,126.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,78.28,
SHODS,61900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SILVER THERMAL HAT,61910,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SLEEVE-STERILE SURGICAL,61935,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SNARE/LG OVAL,61960,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
SNARE POLYPECTOMY,61975,CDM,270,RC,Y7509,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
SMITH PETERSON NAIL,62000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,96,67.2,,,,,,Other,Not Seperately Reimbusable,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,105.18,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
SOCK AID W/CORD,62020,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,724.13,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,476.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SMITH PETERSON PLATE,62050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,2559.07,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,1683.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SPRING GRIP 5MM,62100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,2484.9,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,1634.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,92.4,Other,Not Seperately Reimbusable,,,,99,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SPRING GRIP 12MM,62105,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
STONE BASKET,62210,CDM,270,RC,Y7509,HCPCS,Outpatient,,,323,226.1,,,,,,Other,Not Seperately Reimbusable,219.64,68,,175.71,Percent of Total Billed Charges,68% of Total Billed Charges,245.48,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,161.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.5,245.48,
STONE RET. BASKET,62225,CDM,270,RC,Y7506,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
STYLET,62230,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SUBCLAVIAN INTRO.,62250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
SUCTION KIT-REDI T,62290,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,51.07,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
SUCTION IRRIG. DISP.,62325,CDM,270,RC,Y7509,HCPCS,Outpatient,,,186,130.2,,,,,,Other,Not Seperately Reimbusable,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,141.36,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93,141.36,
SUPPLEMENT SUPLENA,62343,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.28,Other,Not Seperately Reimbusable,,,,38.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,30.72,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.45,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
FEEDING BAG FLUSH SET,62344,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SURGI-KIT,62350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SURGI-NEEDLE,62351,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.6,Other,Not Seperately Reimbusable,,,,18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,84,Other,Not Seperately Reimbusable,,,,90,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
SURGIFOAM,62355,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.56,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.2,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,13.44,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.57,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
SURGICAL BLADE #10,62400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.2,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SURGICAL BLADE #11,62450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,139.23,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,91.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SURGICAL BLADE #12,62500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,318,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
DRESSING POLYMEM MAX SILVER NO,62525,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,317.4,Other,Not Seperately Reimbusable,1,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
SURGICAL BLADE #15,62550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SURGICAL BLADE #21,62600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,22.88,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,75.04,Other,Not Seperately Reimbusable,,,,80.4,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,21.12,Other,Not Seperately Reimbusable,,,,7.18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.18,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SURGICAL BLAD BEAVER,62608,CDM,270,RC,Y7509,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,139.84,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,92,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
SURG.BLADE-KATENA,62625,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SURGICAL SKIN MARKER,62630,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SWIVEL HANDLE &TBNG,62650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
TEMP-A-STRIP,62700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
THREE WAY STOPCOCK,62750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
TISSUE ADHESIVE,62760,CDM,270,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
TOURNIQUET CUFF,62795,CDM,270,RC,Y7506,HCPCS,Outpatient,,,54,37.8,,,,,,Other,Not Seperately Reimbusable,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,41.04,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,27,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,356.72,Other,Not Seperately Reimbusable,,,,411.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,109.76,Other,Not Seperately Reimbusable,,,,329.28,Other,Not Seperately Reimbusable,,,,111.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,111.95,Other,Not Seperately Reimbusable,,,,109.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,109.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,41.04,
TRITON NEEDLE RADIATION MARKER,62825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,98.8,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65,98.8,
TROCAR 12MM BLADED TIP,62845,CDM,270,RC,Y7506,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
TROCAR BLUNT TIP SYR,62850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,261,182.7,,,,,,Other,Not Seperately Reimbusable,177.48,68,,141.98,Percent of Total Billed Charges,68% of Total Billed Charges,198.36,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,130.5,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.5,198.36,
TRACH TUBE-FOME CUF,62855,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
TRACTION BELT-PELVIC,62860,CDM,270,RC,Y7506,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
TROCAR D15 VERSAPORT,62864,CDM,270,RC,Y7506,HCPCS,Outpatient,,,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,783.1,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,515.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
TRACTION BOW,62900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
TRANSDUCER-DISP.,62910,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,120,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
TRANSDUCER COVER,62912,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
THEMODILATION CATH,62915,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
UHS LASER,62916,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1716,1201.2,,,,,,Other,Not Seperately Reimbusable,1166.88,68,,933.5,Percent of Total Billed Charges,68% of Total Billed Charges,1304.16,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,858,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,170.8,Other,Not Seperately Reimbusable,,,,183,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,858,1304.16,
URETERAL ACCESS SHEATH,62918,CDM,270,RC,Y7509,HCPCS,Outpatient,,,211,147.7,,,,,,Other,Not Seperately Reimbusable,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,143.49,Percent of Total Billed Charges,76% of Total Billed Charges,105.5,50,,94.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,160.36,
URETERAL CATH,62919,CDM,270,RC,Y7509,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
TRANSFER TUBING-PK50,62920,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
TUBINE INSUFLAT/FLTR,62921,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
ULNA NERVE PROTECTOR,62922,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
URETERAL DRAIN METER,62923,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
DISP. VEIN STRIPPERS,62925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,43.16,Other,Not Seperately Reimbusable,,,,49.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,13.28,Other,Not Seperately Reimbusable,,,,39.84,Other,Not Seperately Reimbusable,,,,13.54,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.54,Other,Not Seperately Reimbusable,,,,13.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
VASC ACCESS MEDIPORT,62930,CDM,270,RC,Y7506,HCPCS,Outpatient,,,866,606.2,,,,,,Other,Not Seperately Reimbusable,588.88,68,,471.1,Percent of Total Billed Charges,68% of Total Billed Charges,658.16,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,433,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433,658.16,
VENA CAVA CLAMP,62950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.6,Other,Not Seperately Reimbusable,,,,51,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
VENT TUBE-1.00 MM,62975,CDM,270,RC,Y7506,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
VENTRAL SUMP DRAIN,63050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56.56,Other,Not Seperately Reimbusable,,,,60.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
VERSAPORT 5MM,63060,CDM,270,RC,Y7506,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
VERSAPORT 5-12MM,63065,CDM,270,RC,Y7506,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
VERSATEC 4.8MM MULTIFIRE,63070,CDM,270,RC,Y7509,HCPCS,Outpatient,,,247,172.9,,,,,,Other,Not Seperately Reimbusable,167.96,68,,134.37,Percent of Total Billed Charges,68% of Total Billed Charges,187.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,123.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.5,187.72,
VERSATEC RELOAD,63072,CDM,270,RC,Y7509,HCPCS,Outpatient,,,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
VESSELOOPS/PKG,63075,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,22.36,Other,Not Seperately Reimbusable,,,,25.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,146.72,Other,Not Seperately Reimbusable,,,,157.2,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,20.64,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.02,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
VISION BLUE VIAL,63080,CDM,270,RC,Y7509,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,146.72,Other,Not Seperately Reimbusable,,,,157.2,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
VICRYL MESH 12X12 ETHICON,63085,CDM,270,RC,Y7509,HCPCS,Outpatient,,,1445,1011.5,,,,,,Other,Not Seperately Reimbusable,982.6,68,,786.08,Percent of Total Billed Charges,68% of Total Billed Charges,1098.2,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,722.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,722.5,1098.2,
WOUND SPAN,63100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ZIP WIRE,63111,CDM,270,RC,Y7509,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,183.12,Other,Not Seperately Reimbusable,,,,196.2,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
ANTI-FOG FOR LENS,63115,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
EC ACCESSORY KIT,63125,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1784,1248.8,,,,,,Other,Not Seperately Reimbusable,1213.12,68,,970.5,Percent of Total Billed Charges,68% of Total Billed Charges,1355.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,892,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,94.08,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,892,1355.84,
EC OPERATING KIT,63130,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1032,722.4,,,,,,Other,Not Seperately Reimbusable,701.76,68,,561.41,Percent of Total Billed Charges,68% of Total Billed Charges,784.32,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,516,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516,784.32,
ENDO CLIP,63136,CDM,270,RC,Y7506,HCPCS,Outpatient,,,340,238,,,,,,Other,Not Seperately Reimbusable,231.2,68,,184.96,Percent of Total Billed Charges,68% of Total Billed Charges,258.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,170,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170,258.4,
ENDO CUFF,63137,CDM,270,RC,Y7506,HCPCS,Outpatient,,,45,31.5,,,,,,Other,Not Seperately Reimbusable,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,34.2,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,22.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,34.2,
ENDO DISSECT,63138,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,200.72,Other,Not Seperately Reimbusable,,,,231.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,61.76,Other,Not Seperately Reimbusable,,,,185.28,Other,Not Seperately Reimbusable,,,,62.99,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.99,Other,Not Seperately Reimbusable,,,,61.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,61.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
ENDO GRASP,63140,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,437.15,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,287.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
ENDO LOOP,63142,CDM,270,RC,Y7506,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
ENDO SHEARS,63144,CDM,270,RC,Y7506,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,183.12,Other,Not Seperately Reimbusable,,,,196.2,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
FIBER-DISP,63150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,314,219.8,,,,,,Other,Not Seperately Reimbusable,213.52,68,,170.82,Percent of Total Billed Charges,68% of Total Billed Charges,238.64,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,157,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,224.56,Other,Not Seperately Reimbusable,,,,240.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157,238.64,
FIBER-DISP TUR,63152,CDM,270,RC,Y7506,HCPCS,Outpatient,,,1198,838.6,,,,,,Other,Not Seperately Reimbusable,814.64,68,,651.71,Percent of Total Billed Charges,68% of Total Billed Charges,910.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,599,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,599,910.48,
"HOSE, NONST. 7/8""",63155,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,56,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
"HOSE, NONST. 1 1/4""",63157,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,92.4,Other,Not Seperately Reimbusable,,,,99,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
"HOSE, STERILE 7/8""",63165,CDM,270,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
"HOSE, STERILE 1 1/4""",63167,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,206.96,Other,Not Seperately Reimbusable,,,,238.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,63.68,Other,Not Seperately Reimbusable,,,,191.04,Other,Not Seperately Reimbusable,,,,64.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,64.95,Other,Not Seperately Reimbusable,,,,63.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
SUCTION CAN. FOR LZR,63185,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,24.96,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,23.04,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.83,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
SURGI-GRIP,63190,CDM,270,RC,Y7509,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,36.4,Other,Not Seperately Reimbusable,,,,42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,33.6,Other,Not Seperately Reimbusable,,,,11.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.42,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
SURGICLIP 9.0,63195,CDM,270,RC,Y7509,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,107.16,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,196,Other,Not Seperately Reimbusable,,,,210,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,107.16,
AUTO CLIPS,63300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,196,Other,Not Seperately Reimbusable,,,,210,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
EEA-28,63350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,247,172.9,,,,,,Other,Not Seperately Reimbusable,167.96,68,,134.37,Percent of Total Billed Charges,68% of Total Billed Charges,187.72,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,123.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,17.68,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,16.32,Other,Not Seperately Reimbusable,,,,5.55,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.55,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.5,187.72,
DERMABOND,63360,CDM,270,RC,,,Outpatient,,,399,279.3,,,,,,Other,Not Seperately Reimbusable,271.32,68,,217.06,Percent of Total Billed Charges,68% of Total Billed Charges,303.24,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,199.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,259.35,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,299.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,22.96,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,79.8,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,239.4,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,81.4,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,81.4,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,79.8,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,79.8,303.24,
DISP.EEA-21/25/28/31,63375,CDM,270,RC,Y7506,HCPCS,Outpatient,,,632,442.4,,,,,,Other,Not Seperately Reimbusable,429.76,68,,343.81,Percent of Total Billed Charges,68% of Total Billed Charges,480.32,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,316,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,101.36,Other,Not Seperately Reimbusable,,,,108.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,316,480.32,
FACIA STAPLER,63400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
GIA,63450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.76,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,18.24,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.2,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
GIA DISPOSABLE UNIT,63475,CDM,270,RC,Y7506,HCPCS,Outpatient,,,434,303.8,,,,,,Other,Not Seperately Reimbusable,295.12,68,,236.1,Percent of Total Billed Charges,68% of Total Billed Charges,329.84,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,217,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,213.2,Other,Not Seperately Reimbusable,,,,246,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,65.6,Other,Not Seperately Reimbusable,,,,196.8,Other,Not Seperately Reimbusable,,,,66.91,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,66.91,Other,Not Seperately Reimbusable,,,,65.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,65.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217,329.84,
GIA DISP LOAD UNIT,63480,CDM,270,RC,Y7506,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.5,172.52,
LIQUID ADHESIVE-10CC,63490,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.4,Other,Not Seperately Reimbusable,,,,234,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PLDS-15W,63500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,207,144.9,,,,,,Other,Not Seperately Reimbusable,140.76,68,,112.61,Percent of Total Billed Charges,68% of Total Billed Charges,157.32,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,103.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,95.76,Other,Not Seperately Reimbusable,,,,102.6,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,157.32,
PREMIUM PLUS CEEA AS,63510,CDM,270,RC,Y7509,HCPCS,Outpatient,,,733,513.1,,,,,,Other,Not Seperately Reimbusable,498.44,68,,398.75,Percent of Total Billed Charges,68% of Total Billed Charges,557.08,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,366.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.5,557.08,
PURSTRING 65 AUTOSUTURE,63520,CDM,270,RC,Y7509,HCPCS,Outpatient,,,142,99.4,,,,,,Other,Not Seperately Reimbusable,96.56,68,,77.25,Percent of Total Billed Charges,68% of Total Billed Charges,107.92,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,71,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71,107.92,
MICHAEL CLIPS,63550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,101.36,Other,Not Seperately Reimbusable,,,,108.6,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
MICKEY BUTTON,63555,CDM,270,RC,Y7506,HCPCS,Outpatient,,,125,87.5,,,,,,Other,Not Seperately Reimbusable,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,95,
ROTICULATOR 55-3.5,63560,CDM,270,RC,Y7506,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,307.04,76,,51.07,Percent of Total Billed Charges,76% of Total Billed Charges,202,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,307.04,
ROTICULATOR 55-4.5,63570,CDM,270,RC,Y7506,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,307.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,202,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,307.04,
ROTICULATOR POLY-170,63580,CDM,270,RC,Y7506,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,307.04,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,202,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,307.04,
ROTICULATOR POLY-200,63590,CDM,270,RC,Y7506,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,307.04,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,202,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.08,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,1.92,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.66,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,307.04,
SILVER BRAIN CLIPS,63600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,78.96,Other,Not Seperately Reimbusable,,,,84.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
STAPLE GUN,63650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,76.76,
SKIN STAPLER MULTIFIRE PREMIUM,63675,CDM,270,RC,,,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.05,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,27.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,7.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,22.2,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,7.55,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.55,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.4,28.12,
SURGICLIP L-11.5,63750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,131.92,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,147.44,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,97,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,78.96,Other,Not Seperately Reimbusable,,,,84.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97,147.44,
SURGICLIP L-13,63775,CDM,270,RC,Y7509,HCPCS,Outpatient,,,354,247.8,,,,,,Other,Not Seperately Reimbusable,240.72,68,,192.58,Percent of Total Billed Charges,68% of Total Billed Charges,269.04,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,177,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177,269.04,
CLIP-A-MATIC M-20,63800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,236.32,Other,Not Seperately Reimbusable,,,,253.2,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
SUTURE-EYE,63870,CDM,270,RC,Y7509,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,224.56,Other,Not Seperately Reimbusable,,,,240.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
SUTURE D & G,63900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,183.12,Other,Not Seperately Reimbusable,,,,196.2,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SUTURE DEXON,63950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,183.12,Other,Not Seperately Reimbusable,,,,196.2,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE PKG.,64000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,45.24,Other,Not Seperately Reimbusable,,,,52.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,228.48,Other,Not Seperately Reimbusable,,,,244.8,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,41.76,Other,Not Seperately Reimbusable,,,,14.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.2,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
TA 45 LOADING UNIT,64040,CDM,270,RC,Y7509,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.5,104.12,
TA 55-3.5 INSTRUMENT,64050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,234,163.8,,,,,,Other,Not Seperately Reimbusable,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,177.84,
TA 55-4.8 INSTRUMENT,64060,CDM,270,RC,Y7509,HCPCS,Outpatient,,,360,252,,,,,,Other,Not Seperately Reimbusable,244.8,68,,195.84,Percent of Total Billed Charges,68% of Total Billed Charges,273.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,180,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180,273.6,
TA 60,64070,CDM,270,RC,Y7509,HCPCS,Outpatient,,,170,119,,,,,,Other,Not Seperately Reimbusable,115.6,68,,92.48,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,85,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,21.32,Other,Not Seperately Reimbusable,,,,24.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,19.68,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,129.2,
TA 60 RELOADS,64072,CDM,270,RC,Y7509,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,65,Other,Not Seperately Reimbusable,,,,75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,70,Other,Not Seperately Reimbusable,,,,75,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
TA 90-3.5 INSTRUMENT,64075,CDM,270,RC,Y7509,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,64,Percent of Total Billed Charges,50% of Total Billed Charges,,,,55.64,Other,Not Seperately Reimbusable,,,,64.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,51.36,Other,Not Seperately Reimbusable,,,,17.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.46,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
TA 90-4.8 INSTRUMENT,64080,CDM,270,RC,Y7509,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,224.64,Other,Not Seperately Reimbusable,,,,259.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,69.12,Other,Not Seperately Reimbusable,,,,207.36,Other,Not Seperately Reimbusable,,,,70.5,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,70.5,Other,Not Seperately Reimbusable,,,,69.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,69.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,202.92,
TA 90 LOADING UNIT,64090,CDM,270,RC,Y7509,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
SUTURE A186H,64100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,33.8,Other,Not Seperately Reimbusable,,,,39,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,164.64,Other,Not Seperately Reimbusable,,,,176.4,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.61,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUTURE G121H,64150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,379.6,Other,Not Seperately Reimbusable,,,,438,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,230.16,Other,Not Seperately Reimbusable,,,,246.6,Other,Not Seperately Reimbusable,,,,116.8,Other,Not Seperately Reimbusable,,,,350.4,Other,Not Seperately Reimbusable,,,,119.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,119.14,Other,Not Seperately Reimbusable,,,,116.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,116.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G122H,64200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G123H,64250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.12,Other,Not Seperately Reimbusable,,,,61.2,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G321H,64300,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.12,Other,Not Seperately Reimbusable,,,,61.2,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G322H,64350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,85.28,Other,Not Seperately Reimbusable,,,,98.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,26.24,Other,Not Seperately Reimbusable,,,,78.72,Other,Not Seperately Reimbusable,,,,26.77,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.77,Other,Not Seperately Reimbusable,,,,26.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G323H,64400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE G324H,64450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE H820H,64500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE H821H,64550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,54.08,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,49.92,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.98,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE H822H,64600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE K831H,64650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE K832H,64700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE K833H,64750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,204.88,Other,Not Seperately Reimbusable,,,,236.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,63.04,Other,Not Seperately Reimbusable,,,,189.12,Other,Not Seperately Reimbusable,,,,64.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,64.3,Other,Not Seperately Reimbusable,,,,63.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE K834H,64800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,26.52,Other,Not Seperately Reimbusable,,,,30.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,193.2,Other,Not Seperately Reimbusable,,,,207,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,24.48,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE L101G,64850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE L102G,64900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE-MITEK,64920,CDM,270,RC,Y7509,HCPCS,Outpatient,,,293,205.1,,,,,,Other,Not Seperately Reimbusable,199.24,68,,159.39,Percent of Total Billed Charges,68% of Total Billed Charges,222.68,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,146.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.12,Other,Not Seperately Reimbusable,,,,18.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,14.88,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.06,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.5,222.68,
SUTURE N862H,64950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE N863H,65000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.12,Other,Not Seperately Reimbusable,,,,61.2,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE N864H,65050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,193.2,Other,Not Seperately Reimbusable,,,,207,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE S104H,65100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE S172H,65150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE U223H,65200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,96.32,Other,Not Seperately Reimbusable,,,,103.2,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SUTURE U244H,65250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE U245H,65300,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE U246H,65350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE U256H,65400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,311.36,Other,Not Seperately Reimbusable,,,,333.6,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE CB21T,65450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,471.52,Other,Not Seperately Reimbusable,,,,505.2,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
SUTURE CB22T,65500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,647.92,Other,Not Seperately Reimbusable,,,,694.2,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
SUTURE CB27T,65550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,794.08,Other,Not Seperately Reimbusable,,,,850.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
SUTURE CO13T,65600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
SUTURE CO14T,65700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
SUTURE SA64H,65750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE SA65H,65800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,40.56,Other,Not Seperately Reimbusable,,,,46.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.73,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE SA67G,65850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,39,Other,Not Seperately Reimbusable,,,,45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.24,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE SA73H,65900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE SC64H,65950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE SG2T,66000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SUTURE SG3T,66050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SUTURE SG13T,66100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SUTURE SG14T,66150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,39.52,Other,Not Seperately Reimbusable,,,,45.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,683.2,Other,Not Seperately Reimbusable,,,,732,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,36.48,Other,Not Seperately Reimbusable,,,,12.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.4,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SUTURE SG15T,66200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SUTURE SR64H,66250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE SR65H,66300,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,306.32,Other,Not Seperately Reimbusable,,,,328.2,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE SA83H,66350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE SR85H,66400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
TA 45 AUTOSUTURE - TA4535S,66410,CDM,270,RC,Y7509,HCPCS,Outpatient,,,413,289.1,,,,,,Other,Not Seperately Reimbusable,280.84,68,,224.67,Percent of Total Billed Charges,68% of Total Billed Charges,313.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,206.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,313.88,
TA 90 AUTOSUTURE - TA9048S,66420,CDM,270,RC,Y7509,HCPCS,Outpatient,,,244,170.8,,,,,,Other,Not Seperately Reimbusable,165.92,68,,132.74,Percent of Total Billed Charges,68% of Total Billed Charges,185.44,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,122,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122,185.44,
SUTURE 3-622,66450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE 3-628,66500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE 405G,66550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SUTURE 466G,66600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE 467G,66650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,51.48,Other,Not Seperately Reimbusable,,,,59.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,763.84,Other,Not Seperately Reimbusable,,,,818.4,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,47.52,Other,Not Seperately Reimbusable,,,,16.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.16,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE 482G,66700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
SUTURE 622H,66750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 627H,66800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 627G,66850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 629G,66900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 636G,66950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 662G,67000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,23.92,Other,Not Seperately Reimbusable,,,,27.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,22.08,Other,Not Seperately Reimbusable,,,,7.5,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.5,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 662H,67050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,121.68,Other,Not Seperately Reimbusable,,,,140.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,227.92,Other,Not Seperately Reimbusable,,,,244.2,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,112.32,Other,Not Seperately Reimbusable,,,,38.19,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.19,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 663G,67100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,26,Other,Not Seperately Reimbusable,,,,30,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 664H,67150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 668G,67200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,96.72,Other,Not Seperately Reimbusable,,,,111.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,89.28,Other,Not Seperately Reimbusable,,,,30.35,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.35,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 682H,67250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,98.28,Other,Not Seperately Reimbusable,,,,113.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,90.72,Other,Not Seperately Reimbusable,,,,30.85,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.85,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 683H,67300,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.04,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 684H,67350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 711G,67400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,9.88,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.1,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 811H,67450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 812H,67500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,71.24,Other,Not Seperately Reimbusable,,,,82.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,65.76,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.36,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 813H,67550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 815H,67600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE 816H,67650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE 842H,67700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,640.08,Other,Not Seperately Reimbusable,,,,685.8,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 873H,67750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 1637G,67800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,16.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,15.36,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.22,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE 1698G,67850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,50.44,Other,Not Seperately Reimbusable,,,,58.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,46.56,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SUTURE 8614G,67900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUTURE 594-61,67950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 1076-31,68000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,55.33,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,36.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 1076-41,68050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,63.23,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 1076-51,68100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,79.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7006-71,68150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,71.76,Other,Not Seperately Reimbusable,,,,82.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,22.08,Other,Not Seperately Reimbusable,,,,66.24,Other,Not Seperately Reimbusable,,,,22.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.52,Other,Not Seperately Reimbusable,,,,22.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7248-51,68200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,57.2,Other,Not Seperately Reimbusable,,,,66,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,52.8,Other,Not Seperately Reimbusable,,,,17.95,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.95,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7266-51,68250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7266-61,68350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7266-71,68400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,246.24,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.8,Other,Not Seperately Reimbusable,,,,9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.45,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7267-51,68450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,61.88,Other,Not Seperately Reimbusable,,,,71.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,19.04,Other,Not Seperately Reimbusable,,,,57.12,Other,Not Seperately Reimbusable,,,,19.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.42,Other,Not Seperately Reimbusable,,,,19.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,19.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7538-11,68500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,15.6,Other,Not Seperately Reimbusable,,,,18,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.9,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7608-31,68550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7608-41,68600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,178.36,Other,Not Seperately Reimbusable,,,,205.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,54.88,Other,Not Seperately Reimbusable,,,,164.64,Other,Not Seperately Reimbusable,,,,55.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,55.98,Other,Not Seperately Reimbusable,,,,54.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.88,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7609-31,68650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.92,Other,Not Seperately Reimbusable,,,,12.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.42,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7609-41,68700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.72,Other,Not Seperately Reimbusable,,,,21.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,730.8,Other,Not Seperately Reimbusable,,,,783,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,17.28,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.87,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7754-41,68750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,55.64,Other,Not Seperately Reimbusable,,,,64.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,626.08,Other,Not Seperately Reimbusable,,,,670.8,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,51.36,Other,Not Seperately Reimbusable,,,,17.46,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.46,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUTURE 7754-51,68800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,152.88,Other,Not Seperately Reimbusable,,,,176.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,89.04,Other,Not Seperately Reimbusable,,,,95.4,Other,Not Seperately Reimbusable,,,,47.04,Other,Not Seperately Reimbusable,,,,141.12,Other,Not Seperately Reimbusable,,,,47.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.98,Other,Not Seperately Reimbusable,,,,47.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
ASEPTO SYRG.-DISP.,69000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,50.44,Other,Not Seperately Reimbusable,,,,58.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,647.92,Other,Not Seperately Reimbusable,,,,694.2,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,46.56,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.83,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ASEPTO SYRG. GLS 2OZ,69050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,706.16,Other,Not Seperately Reimbusable,,,,756.6,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ASEPTO SYRG. GLS 3OZ,69100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,852.88,Other,Not Seperately Reimbusable,,,,913.8,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
BIOPSY NDLE.41/2-DIS,69150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,37.44,Other,Not Seperately Reimbusable,,,,43.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,34.56,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.75,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
PROSTATE BIOPSY PUNCH,69180,CDM,270,RC,Y7509,HCPCS,Outpatient,,,129,90.3,,,,,,Other,Not Seperately Reimbusable,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,98.04,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,64.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.5,98.04,
BIOPSY NDLE.6-DISP,69200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,69.92,
BIOPSY NEEDLE-BREAST,69204,CDM,270,RC,Y7509,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
BIOPSY SYSTEM-18 GA,69210,CDM,270,RC,Y7509,HCPCS,Outpatient,,,124,86.8,,,,,,Other,Not Seperately Reimbusable,84.32,68,,67.46,Percent of Total Billed Charges,68% of Total Billed Charges,94.24,76,,80.86,Percent of Total Billed Charges,76% of Total Billed Charges,62,50,,53.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.32,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,7.68,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.61,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62,94.24,
CLICK-LOCK NEEDLE,69220,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1005.63,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,661.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
EAR & ULCER SYRINGE,69300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,653.6,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,430,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
DISP NEEDLE GASTRO,69309,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,783.1,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,515.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
EPIDURAL NDL 16 GA,69320,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,69.68,Other,Not Seperately Reimbusable,,,,80.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,21.44,Other,Not Seperately Reimbusable,,,,64.32,Other,Not Seperately Reimbusable,,,,21.87,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.87,Other,Not Seperately Reimbusable,,,,21.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
FEEDING SYRG-10 10CC,69350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,4.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,412.16,Other,Not Seperately Reimbusable,,,,441.6,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HUBER GRIPPER NDL.,69366,CDM,270,RC,Y7509,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,211.58,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,25.48,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,23.52,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
HUBER NEEDLE,69370,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,29.92,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
IRRIGATION SET,69500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,29.92,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ANCHOR NEEDLES,69601,CDM,270,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
PER-Q CATH NEEDLE,69682,CDM,270,RC,Y7509,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,278.72,Other,Not Seperately Reimbusable,,,,321.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,85.76,Other,Not Seperately Reimbusable,,,,257.28,Other,Not Seperately Reimbusable,,,,87.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,87.47,Other,Not Seperately Reimbusable,,,,85.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,198.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
SPINAL NEEDL.20GX3.5,70150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1368.7,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,72.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,217.88,Other,Not Seperately Reimbusable,,,,251.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,67.04,Other,Not Seperately Reimbusable,,,,201.12,Other,Not Seperately Reimbusable,,,,68.38,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,68.38,Other,Not Seperately Reimbusable,,,,67.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SPINAL NDLE. 22GX2.5,70175,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,174.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,643.76,Other,Not Seperately Reimbusable,,,,742.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,198.08,Other,Not Seperately Reimbusable,,,,594.24,Other,Not Seperately Reimbusable,,,,202.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,202.04,Other,Not Seperately Reimbusable,,,,198.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SPINAL NEEDL.22GX3.5,70200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,91,Other,Not Seperately Reimbusable,,,,105,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,28,Other,Not Seperately Reimbusable,,,,84,Other,Not Seperately Reimbusable,,,,28.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.56,Other,Not Seperately Reimbusable,,,,28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SPINAL NEEDL.25GX3.5,70250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SPINAL NEEDLES 140MM,70254,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SYRG/NDL 3CC 21X1,70285,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SYRINGE 3CC,70300,CDM,270,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,302.96,Other,Not Seperately Reimbusable,,,,324.6,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
SYRINGE 10CC,70364,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,593.04,Other,Not Seperately Reimbusable,,,,635.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SYRINGE TB,70369,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SYRINGE 30CC,70400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,153.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,705.6,Other,Not Seperately Reimbusable,,,,756,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SYRINGE 50CC,70450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,268,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SYRINGE 60CC,70500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,436,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SYRINGE/GAUGE ASSEMBLY 60CC,70600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
WINGED INFUSION SET,70825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,396.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
CONFORM TAPE 2,71000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
CONFORM TAPE 3,71050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CONFORM TAPE 4,71100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
DERMICEL TAPE 1,71150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1394.27,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DERMICEL TAPE 2,71200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DERMICEL TAPE 3,71250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
DERMIFORM TAPE 1IN.,71300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DERMIFORM TAPE 2IN.,71350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MICROFOAM-3 IN.,71360,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
MICROFOAM PATCH TAPE,71380,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MICROPORE TAPE 1,71400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,51.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MICROPORE TAPE 2,71450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
MICROPORE TAPE 3,71500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
POROUS TAPE 1 IN,71600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,346,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
POROUS TAPE 2 IN,71650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,2014.98,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,346,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
POROUS TAPE 3 IN,71700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
TRANSPORE TAPE-1IN,71725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1368.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,224.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
"WATERPROOF TAPE 2""",71740,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
"COBAN 4"" TAPE",71750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,76.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
"COBAN TAPE-21""",71760,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
AMNIOCENTESIS TRAY,71900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,1368.7,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,640.08,Other,Not Seperately Reimbusable,,,,685.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
ARTHOGRAM TRAY,71932,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
ASPIRATION TRAY,71950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BLOOD EXCHANGE TRAY,72000,CDM,270,RC,Y7507,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,13.6,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
BONE MARROW BIOPSY T,72050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
CATARACT TRAY,72075,CDM,270,RC,Y7509,HCPCS,Outpatient,,,899,629.3,,,,,,Other,Not Seperately Reimbusable,611.32,68,,489.06,Percent of Total Billed Charges,68% of Total Billed Charges,683.24,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,449.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,758.8,Other,Not Seperately Reimbusable,,,,813,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.5,683.24,
CIRCUMCISION TRAY,72100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,607.6,Other,Not Seperately Reimbusable,,,,651,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
CULDECENTESIS TRAY,72130,CDM,270,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,198.8,Other,Not Seperately Reimbusable,,,,213,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
CUTDOWN TRAY,72150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,2014.98,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,134,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,310.8,Other,Not Seperately Reimbusable,,,,333,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
DRESSING TRAY,72200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1368.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,271.04,Other,Not Seperately Reimbusable,,,,290.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DRESSINET,72225,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,173.6,Other,Not Seperately Reimbusable,,,,186,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
EAR & EYE TRAY,72250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
EPIDURAL TY CONT 18G,72251,CDM,270,RC,Y7509,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
FACIAL WOUND TRAY,72300,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
GEL PREP KIT,72350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,953.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
HYPERAL. DRESS. TRAY,72375,CDM,270,RC,Y7509,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,1368.7,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,71.12,Other,Not Seperately Reimbusable,,,,76.2,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,,,,,Other,Not Seperately Reimbusable,12,18.24,
INCISION DRAIN TRAY,72400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1002.05,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,436.24,Other,Not Seperately Reimbusable,,,,467.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
IV CATH TRAY,72410,CDM,270,RC,Y7509,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,466.48,Other,Not Seperately Reimbusable,,,,499.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
IV DRESSING ADHESIVE,72414,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,1282.21,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,282.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
LAP INST. TRAY,72450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,1015.1,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
TRAY BIOPSY,72500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
LUMBAR TRAY-ADULT,72550,CDM,270,RC,Y7509,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,110.66,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,630.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
LUMBAR TRAY-PED.,72600,CDM,270,RC,Y7509,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,265.09,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
MANOMETER TRAY,72650,CDM,270,RC,Y7509,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
MINOR INST. TRAY,72700,CDM,270,RC,Y7509,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,211.58,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
NASAL TRAY,72750,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,211.58,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
OB DISPO TRAY,72800,CDM,270,RC,Y7509,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,510.72,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
OB TRAY-REUSABLE,72820,CDM,270,RC,Y7509,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,178.14,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
PARA THORACOT TRAY,72850,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,510.72,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PCV INSERTION TRAY,72875,CDM,270,RC,Y7509,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
BARD MESH PERFIX PLUG LARGE,72876,CDM,270,RC,,,Outpatient,,,630,441,,,,,,Other,Not Seperately Reimbusable,428.4,68,,342.72,Percent of Total Billed Charges,68% of Total Billed Charges,478.8,76,,211.58,Percent of Total Billed Charges,76% of Total Billed Charges,315,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,409.5,65,,327.6,Percent of Total Billed Charges,65% of Total Billed Charges,472.5,75,,378,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,126,20,,100.8,Percent of Total Billed Charges,20% of Total Billed Charges,378,60,,302.4,Percent of Total Billed Charges,60% of Total Billed Charges,128.52,20.4,,102.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,128.52,20.4,,102.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,126,20,,100.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,20,,100.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,126,478.8,
PNEUMOTHORAX KIT,72880,CDM,270,RC,Y7506,HCPCS,Outpatient,,,173,121.1,,,,,,Other,Not Seperately Reimbusable,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,113.7,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.5,131.48,
PREP KIT,72890,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PREP TRAY,72900,CDM,270,RC,Y7509,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,285.06,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,711.76,Other,Not Seperately Reimbusable,,,,762.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
PREP SOLUTION-SURGICAL,72910,CDM,270,RC,Y7509,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,406.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
PUDENDAL BLOCK TRAY,72950,CDM,270,RC,Y7509,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,190.4,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
SADDLE BLOCK TRAY,73000,CDM,270,RC,Y7509,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,519.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SADDLE BLOCK TRAY 22,73003,CDM,270,RC,Y7509,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,71.44,
SPINAL ANEST TR 22GA,73004,CDM,270,RC,Y7509,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
SPINAL ANEST.TRY 25G,73050,CDM,270,RC,Y7509,HCPCS,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,378.56,Other,Not Seperately Reimbusable,,,,405.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
SUTURE REMOVAL TRAY,73100,CDM,270,RC,Y7509,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
THORACENTESIS TRAY,73150,CDM,270,RC,Y7509,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,79.8,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,79.8,
THORACENT. TRAY-DISP,73175,CDM,270,RC,Y7509,HCPCS,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,277.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
TRACH CLEANING TRAY,73200,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,199.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
TRACHEOSTOMY COLLAR CARE KIT,73210,CDM,270,RC,A4625,HCPCS,Outpatient,,,57,39.9,,4.84,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,77.82,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,399.28,Other,Not Seperately Reimbusable,,,,427.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
TRACH-INNER CANNALA,73225,CDM,270,RC,Y7509,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,89.98,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
TRACHEOSTOMY TRAY,73250,CDM,270,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,89.98,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,210,Other,Not Seperately Reimbusable,,,,225,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
TRACH TUBE PED TTS CUFFED 3.0M,73300,CDM,270,RC,,,Outpatient,,,229,160.3,,,,,,Other,Not Seperately Reimbusable,155.72,68,,124.58,Percent of Total Billed Charges,68% of Total Billed Charges,174.04,76,,525.92,Percent of Total Billed Charges,76% of Total Billed Charges,114.5,50,,84.4,Percent of Total Billed Charges,50% of Total Billed Charges,148.85,65,,119.08,Percent of Total Billed Charges,65% of Total Billed Charges,171.75,75,,137.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,45.8,20,,36.64,Percent of Total Billed Charges,20% of Total Billed Charges,137.4,60,,109.92,Percent of Total Billed Charges,60% of Total Billed Charges,46.72,20.4,,37.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.72,20.4,,37.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,45.8,20,,36.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.8,20,,36.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.8,174.04,
TRACH TUBE PED TTS CUFFED 3.5M,73301,CDM,270,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,525.92,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
TRACH TUBE PED TTS CUFFED 4.0M,73302,CDM,270,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,108.83,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
TRACH TUBE PED TTS 4.5MM,73303,CDM,270,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,341.7,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
TRACH TUBE PED TTS CUFFED 5.0M,73304,CDM,270,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,108.83,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,763.28,Other,Not Seperately Reimbusable,,,,817.8,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
TRACH TUBE PED TTS 5.5MM,73305,CDM,270,RC,,,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,156.4,68,,125.12,Percent of Total Billed Charges,68% of Total Billed Charges,174.8,76,,116.13,Percent of Total Billed Charges,76% of Total Billed Charges,115,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,149.5,65,,119.6,Percent of Total Billed Charges,65% of Total Billed Charges,172.5,75,,138,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,138,60,,110.4,Percent of Total Billed Charges,60% of Total Billed Charges,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46.92,20.4,,37.54,Percent of Total Billed Charges,20.4% of Total Billed Charges,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,20,,36.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,46,174.8,
TRACH TUBE BIVONA TTS 7.0MM; A,73306,CDM,270,RC,,,Outpatient,,,97,67.9,,,,,,Other,Not Seperately Reimbusable,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,73.72,76,,108.83,Percent of Total Billed Charges,76% of Total Billed Charges,48.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,63.05,65,,50.44,Percent of Total Billed Charges,65% of Total Billed Charges,72.75,75,,58.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,726.88,Other,Not Seperately Reimbusable,,,,778.8,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,58.2,60,,46.56,Percent of Total Billed Charges,60% of Total Billed Charges,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,73.72,
TRACH TUBE BIVONA TTS 7.5MM; A,73307,CDM,270,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,525.92,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,726.88,Other,Not Seperately Reimbusable,,,,778.8,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
TRACH TUBE BIVONA TTS 8.00MM;,73308,CDM,270,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,108.83,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
TRACH TUBE BIVONA TTS 6.0MM; A,73309,CDM,270,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,108.83,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
TRACH TUBE CUFFED BLUE LINE PO,73310,CDM,270,RC,,,Outpatient,,,45,31.5,,,,,,Other,Not Seperately Reimbusable,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,34.2,76,,122.82,Percent of Total Billed Charges,76% of Total Billed Charges,22.5,50,,417.6,Percent of Total Billed Charges,50% of Total Billed Charges,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,33.75,75,,27,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,27,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,34.2,
TRACH TUBE UNCUFF BLUE LINE PO,73311,CDM,270,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,127.68,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
TRACH TUBE CUFFED BLUE LINE PO,73312,CDM,270,RC,,,Outpatient,,,45,31.5,,,,,,Other,Not Seperately Reimbusable,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,34.2,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,22.5,50,,417.6,Percent of Total Billed Charges,50% of Total Billed Charges,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,33.75,75,,27,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,27,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,34.2,
TRACH TUBE UNCUFF BLUE LINE PO,73313,CDM,270,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
TRACH TUBE FENESTRATED DIC CUF,73314,CDM,270,RC,,,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
TRACH TUBE PED UNCUFFED BIVONA,73315,CDM,270,RC,,,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,50.7,65,,40.56,Percent of Total Billed Charges,65% of Total Billed Charges,58.5,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,383.6,Other,Not Seperately Reimbusable,,,,411,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,46.8,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.6,59.28,
TRACH TUBE PED UNCUFFED BIVONA,73316,CDM,270,RC,,,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,182.24,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,50.7,65,,40.56,Percent of Total Billed Charges,65% of Total Billed Charges,58.5,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,46.8,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.6,59.28,
TRACH TUBE PED UNCUFFED BIVONA,73317,CDM,270,RC,,,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,50.7,65,,40.56,Percent of Total Billed Charges,65% of Total Billed Charges,58.5,75,,46.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,46.8,60,,37.44,Percent of Total Billed Charges,60% of Total Billed Charges,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.91,20.4,,12.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.6,20,,12.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15.6,59.28,
TRACH TUBE CUFFED FENSTRA 8.0M,73318,CDM,270,RC,,,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,436.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,19.76,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,22.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,18.24,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,6.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,6.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
TRAY W/O INSTRUMENTS,73350,CDM,270,RC,Y7509,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,54.94,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,383.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,514.64,Other,Not Seperately Reimbusable,,,,551.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
BARD MESH PERFIX PLUG XLARGE,73398,CDM,270,RC,,,Outpatient,,,720,504,,,,,,Other,Not Seperately Reimbusable,489.6,68,,391.68,Percent of Total Billed Charges,68% of Total Billed Charges,547.2,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,360,50,,324.8,Percent of Total Billed Charges,50% of Total Billed Charges,468,65,,374.4,Percent of Total Billed Charges,65% of Total Billed Charges,540,75,,432,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,144,20,,115.2,Percent of Total Billed Charges,20% of Total Billed Charges,432,60,,345.6,Percent of Total Billed Charges,60% of Total Billed Charges,146.88,20.4,,117.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,146.88,20.4,,117.5,Percent of Total Billed Charges,20.4% of Total Billed Charges,144,20,,115.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144,20,,115.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,144,547.2,
UMBILICAL CATH. TRAY,73400,CDM,270,RC,Y7509,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,763.84,Other,Not Seperately Reimbusable,,,,818.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
BARD SOFT MESH 3X6,73402,CDM,270,RC,,,Outpatient,,,300,210,,,,,,Other,Not Seperately Reimbusable,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,228,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,150,50,,296.8,Percent of Total Billed Charges,50% of Total Billed Charges,195,65,,156,Percent of Total Billed Charges,65% of Total Billed Charges,225,75,,180,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,180,60,,144,Percent of Total Billed Charges,60% of Total Billed Charges,61.2,20.4,,48.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,61.2,20.4,,48.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,20,,48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60,228,
UTILITY TRAY,73450,CDM,270,RC,Y7509,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,296.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,427.28,Other,Not Seperately Reimbusable,,,,457.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
WOUND CLOSURE TRAY,73500,CDM,270,RC,Y7509,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,296.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ALLEVYN LIFE DRESS SAC SM 63/4,73692,CDM,270,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,767.2,Other,Not Seperately Reimbusable,,,,822,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
WRIST SPLINT UNV RT,73737,CDM,270,RC,L3908,HCPCS,Outpatient,,,11,7.7,,33.93,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,768.88,Other,Not Seperately Reimbusable,,,,823.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
WRIST SPLINT UNV LEFT,73738,CDM,270,RC,L3908,HCPCS,Outpatient,,,11,7.7,,33.93,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,791.28,Other,Not Seperately Reimbusable,,,,847.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
SILIC.CATH.12FR 5CC,73750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,130.48,Other,Not Seperately Reimbusable,,,,139.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
ALLEVYN LIFE FOAM DRESS 8-1/2X,73775,CDM,270,RC,,,Outpatient,,,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,47.45,65,,37.96,Percent of Total Billed Charges,65% of Total Billed Charges,54.75,75,,43.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,151.2,Other,Not Seperately Reimbusable,,,,162,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,43.8,60,,35.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,55.48,
GLUCERNA 1.5 CAL,73776,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,212,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,456.96,Other,Not Seperately Reimbusable,,,,489.6,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
BOOT WALKER XCELTRAX AIR,73779,CDM,270,RC,,,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,71.44,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,47,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,61.1,65,,48.88,Percent of Total Billed Charges,65% of Total Billed Charges,70.5,75,,56.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,86.24,Other,Not Seperately Reimbusable,,,,92.4,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,56.4,60,,45.12,Percent of Total Billed Charges,60% of Total Billed Charges,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.18,20.4,,15.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.8,20,,15.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.8,71.44,
SILIC.CATH.14FR 5CC,73800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,376.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,154,Other,Not Seperately Reimbusable,,,,165,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
INNER CANNULA 7.0MM DISPOSABLE,73801,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,9.52,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
SILIC.CATH.16FR 5CC,73850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,58.8,Other,Not Seperately Reimbusable,,,,63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.18FR 5CC,73900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,258.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,357.84,Other,Not Seperately Reimbusable,,,,383.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.20FR 5CC,73950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,710.64,Other,Not Seperately Reimbusable,,,,761.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.22FR 5CC,74000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,27.74,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.24FR 5CC,74050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.26FR 5CC,74100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,464.8,Other,Not Seperately Reimbusable,,,,498,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.28FR 5CC,74150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.30FR 5CC,74200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,290.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.14FR 30CC,74250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SILIC.CATH.16FR 30CC,74300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,258.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.18FR 30CC,74350,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,252.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.20FR 30CC,74400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,101.36,Other,Not Seperately Reimbusable,,,,108.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.22FR 30CC,74450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.72,Other,Not Seperately Reimbusable,,,,22.2,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,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.24FR 30CC,74500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,847.28,Other,Not Seperately Reimbusable,,,,907.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
SILIC.CATH.26FR 30CC,74550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,377.54,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,110.88,Other,Not Seperately Reimbusable,,,,118.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
CATH FOLEY 28FR 30CC 2-WAY,74600,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,270.91,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,191.52,Other,Not Seperately Reimbusable,,,,205.2,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
CATH FOLEY 30FR 5CC 2-WAY,74650,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,51.52,Other,Not Seperately Reimbusable,,,,55.2,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
2-WAY CATH. 8FR 3CC,74700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,223.44,Other,Not Seperately Reimbusable,,,,239.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
CATHETER FOLEY 22FR 5CC 2WAY 2,74701,CDM,270,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,59.92,Other,Not Seperately Reimbusable,,,,64.2,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
2-WAY CATH.10FR 3CC,74750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,114.78,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,96.32,Other,Not Seperately Reimbusable,,,,103.2,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,,,,,Other,Not Seperately Reimbusable,16,24.32,
2-WAY CATH.12FR 5CC,74800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,82.88,Other,Not Seperately Reimbusable,,,,88.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
2-WAY CATH.14FR 5CC,74850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,112.56,Other,Not Seperately Reimbusable,,,,120.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
2-WAY CATH.16FR 5CC,74900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,172.48,Other,Not Seperately Reimbusable,,,,184.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
CATH FOLEY 20FR 30CC 2-WAY,75000,CDM,270,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,91.28,Other,Not Seperately Reimbusable,,,,97.8,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
PIRANHA FORCEP,75020,CDM,270,RC,Y7506,HCPCS,Outpatient,,,719,503.3,,,,,,Other,Not Seperately Reimbusable,488.92,68,,391.14,Percent of Total Billed Charges,68% of Total Billed Charges,546.44,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,359.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,77.28,Other,Not Seperately Reimbusable,,,,82.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.5,546.44,
2-WAY CATH.22FR 5CC,75050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,125.44,Other,Not Seperately Reimbusable,,,,134.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
2-WAY CATH.24FR 5CC,75100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,40.32,Other,Not Seperately Reimbusable,,,,43.2,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,,,,,Other,Not Seperately Reimbusable,11,16.72,
2-WAY CATH 14FR 30CC,75109,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,120.96,Other,Not Seperately Reimbusable,,,,129.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
CATH FOLEY 16FR 30CC 2-WAY,75150,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,46.48,Other,Not Seperately Reimbusable,,,,49.8,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
2-WAY CATH.18FR 30CC,75200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,51.52,Other,Not Seperately Reimbusable,,,,55.2,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,,,,,Other,Not Seperately Reimbusable,12.5,19,
2-WAY CATH.20FR 30CC,75250,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,90.72,Other,Not Seperately Reimbusable,,,,97.2,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,,,,,Other,Not Seperately Reimbusable,12.5,19,
3-WAY CATH.16FR 5CC,75400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,89.76,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,878.08,Other,Not Seperately Reimbusable,,,,940.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
CATH FOLEY 18FR 5CC 3 WAY,75450,CDM,270,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,89.04,Other,Not Seperately Reimbusable,,,,95.4,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
3-WAY CATH.20FR 5CC,75500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,52.77,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,108,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.22FR 5CC,75550,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,72.24,Other,Not Seperately Reimbusable,,,,77.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.24FR 5CC,75600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,258.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.68,Other,Not Seperately Reimbusable,,,,61.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.18FR 30CC,75700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,68.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,102.48,Other,Not Seperately Reimbusable,,,,109.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.20FR 30CC,75750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,282.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,197.68,Other,Not Seperately Reimbusable,,,,211.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.22FR 30CC,75800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,282,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,108,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
3-WAY CATH.24FR 30CC,75850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,282.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,80.64,Other,Not Seperately Reimbusable,,,,86.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
CATH FOLEY 26FR 30CC 3WAY,75900,CDM,270,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,282.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,57.68,Other,Not Seperately Reimbusable,,,,61.8,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
"BAG, BILE",76100,CDM,270,RC,Y7506,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,282.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,44.8,Other,Not Seperately Reimbusable,,,,48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
"BAG, DISPOZA",76150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,123.76,Other,Not Seperately Reimbusable,,,,132.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
CATHETER PLUG,76200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,104.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,136.64,Other,Not Seperately Reimbusable,,,,146.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
CATH.FOLEY TRAY 16FR DRAIN BAG,76350,CDM,270,RC,,,Outpatient,,,15,10.5,,,,,,Other,Not Seperately Reimbusable,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,102.14,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.75,65,,7.8,Percent of Total Billed Charges,65% of Total Billed Charges,11.25,75,,9,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,33.04,Other,Not Seperately Reimbusable,,,,35.4,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,9,60,,7.2,Percent of Total Billed Charges,60% of Total Billed Charges,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.06,20.4,,2.45,Percent of Total Billed Charges,20.4% of Total Billed Charges,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,20,,2.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3,11.4,
CUNNINGHAM CLAMP,76450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,65.28,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,130.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.88,Other,Not Seperately Reimbusable,,,,58.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
DRAIN BAG,76500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,65.28,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,80.08,Other,Not Seperately Reimbusable,,,,85.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
GLYCINE 1.5  1500ML,76550,CDM,270,RC,Y7506,HCPCS,Outpatient,500,ML,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,113.12,Other,Not Seperately Reimbusable,,,,121.2,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,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
GLYCINE 1.5 3000ML,76551,CDM,270,RC,Y7506,HCPCS,Outpatient,3000,ML,84,58.8,,,,,,Other,Not Seperately Reimbusable,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,288.32,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,115.92,Other,Not Seperately Reimbusable,,,,124.2,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,,,,,Other,Not Seperately Reimbusable,42,63.84,
MALE INCONTINENT BAG,76600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,287.78,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,117.6,Other,Not Seperately Reimbusable,,,,126,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SODIUM CHLORIDE 250M,76601,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.48,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SODIUM CHLORIDE/IRR 1000,76650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,72.9,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
SODIUM CHLORIDE/IRR 1500,76700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.76,Other,Not Seperately Reimbusable,,,,42.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
SODIUM CHLORIDE/2000CC,76725,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,351.97,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.64,Other,Not Seperately Reimbusable,,,,11.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
STERILE WATER/IRR 1500,76750,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,130.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,191.52,Other,Not Seperately Reimbusable,,,,205.2,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
STERILE WATER/2000CC,76775,CDM,270,RC,Y7506,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,160.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
TUOHY NEEDLE,76845,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.6,Other,Not Seperately Reimbusable,,,,51,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TUR IRRIG SET Y TYPE,76850,CDM,270,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,73.92,Other,Not Seperately Reimbusable,,,,79.2,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
TUR SET Y-TYPE-TRAV.,76851,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,112.56,Other,Not Seperately Reimbusable,,,,120.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
U-BAG PEDIATRIC,76900,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,436.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,478.24,Other,Not Seperately Reimbusable,,,,512.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
U-BAG INFANT,76925,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,351.97,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,120.96,Other,Not Seperately Reimbusable,,,,129.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
URETHRAL TRAY 10FR,76950,CDM,270,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,343.81,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.44,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
URETHRAL TRAY W/CATH,77000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.44,Other,Not Seperately Reimbusable,,,,29.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
URINE DRAIN BAG 2500ML W/350ML,77050,CDM,270,RC,,,Outpatient,50,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,72.8,Other,Not Seperately Reimbusable,,,,78,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
UROGATE SET,77100,CDM,270,RC,,,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,84.8,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,18.2,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,21,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,67.2,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,16.8,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.71,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
TUR SERIES SET,77101,CDM,270,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,78.4,Other,Not Seperately Reimbusable,,,,84,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
UROLOGICAL FILTERS,77150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,228.48,Other,Not Seperately Reimbusable,,,,244.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
STONE RETIV FILF TIP,77151,CDM,270,RC,Y7506,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,,,,27,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
PLUNGER,78200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,67.2,Other,Not Seperately Reimbusable,,,,72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
PADS-ALCOHOL,80068,CDM,270,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,46.24,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
IMMOBLIZER SHOULDER DELUXE UNI,80549,CDM,270,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,5.72,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,6.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,5.28,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,1.79,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,1.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
8.0 DISPOSABLE INNER CANNULA,80788,CDM,270,RC,A4623,HCPCS,Outpatient,,,5,3.5,,4.09,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,351.97,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,168.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
POLYSKIN II 2X2 3/4,202226,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,93.02,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,160.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
POLYSKIN II 4X4 3/4,202259,CDM,270,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,130.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SKIN BARRIER WIPES,206854,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,130.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SPECIMEN PAN 1000ML,253825,CDM,270,RC,,,Outpatient,1000,ML,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,163.2,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
SODIUM CHLORIDE O.9% 30CC,341081,CDM,270,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,465.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FOLEY CATHETER TRAY 16/5,350010,CDM,270,RC,A4314,HCPCS,Outpatient,,,25,17.5,,15.77,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
FOLEY CATHETER TRAY 18/5,350015,CDM,270,RC,A4314,HCPCS,Outpatient,,,74,51.8,,15.77,100,,,fee schedule,100% Aetna Market fee schedule,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,142.53,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,302.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
FOLEY CATHETER TRAY-ADD A,350025,CDM,270,RC,A4354,HCPCS,Outpatient,,,44,30.8,,8.66,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
FOLEY CATHETER 2-WAY 24/5,350030,CDM,270,RC,A4340,HCPCS,Outpatient,,,61,42.7,,23.3,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,286,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
FOLEY CATHETER 3-WAY 16/5,350035,CDM,270,RC,A4346,HCPCS,Outpatient,,,38,26.6,,14.13,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,297.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
FOLEY CATHETER 2-WAY 20/5,350040,CDM,270,RC,A4338,HCPCS,Outpatient,,,25,17.5,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,177.89,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,117.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
FOLEY CATHETER 2-WAY 18/5,350045,CDM,270,RC,A4338,HCPCS,Outpatient,,,22,15.4,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,164.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
FOLEY CATHETER 2-WAY 22/5,350050,CDM,270,RC,A4338,HCPCS,Outpatient,,,21,14.7,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,91.39,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,270,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
FOLEY CATHETER 2-WAY 16/30,350055,CDM,270,RC,A4338,HCPCS,Outpatient,,,48,33.6,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,40.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
FOLEY CATHETER 2-WAY 18/30,350060,CDM,270,RC,A4338,HCPCS,Outpatient,,,25,17.5,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,40.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
NASAL GASTRIC TUVE W/STYLET 12,350065,CDM,270,RC,B4081,HCPCS,Outpatient,,,40,28,,12.66,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,244.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
GASTROSTOMY TUBE 16,350070,CDM,270,RC,B4085,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
GASTROSTOMY TUBE 18,350075,CDM,270,RC,B4085,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,320,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
GASTROSTOMY TUBE 22,350080,CDM,270,RC,B4085,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
GASTROSTOMY TUBE 24,350085,CDM,270,RC,B4085,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,177.89,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
TRANSPORE TAPE,350090,CDM,270,RC,A6265,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,218.14,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MICROPORE SURGICAL PAPER TAPE,350095,CDM,270,RC,A6265,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,54.4,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,423.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
IRRIGATION TRAY,350100,CDM,270,RC,A4320,HCPCS,Outpatient,,,21,14.7,,3.86,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,54.4,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
OVAL EYE PAD,350115,CDM,270,RC,A6402,HCPCS,Outpatient,,,3,2.1,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ADGSTIC DRESSING 3X3,350120,CDM,270,RC,A6222,HCPCS,Outpatient,,,8,5.6,,1.57,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
IODOFORM PACKING STRIPS 1/4 X,350125,CDM,270,RC,A6266,HCPCS,Outpatient,,,15,10.5,,1.4,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,248.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
IODOFORM PACKING STRIPS 2IN,350126,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,190.4,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
"3"" ADHESIVE WOUND DRESSING 6X6",350130,CDM,270,RC,A6220,HCPCS,Outpatient,,,9,6.3,,1.9,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,40.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
TEGADERM 4X4 3/4,350135,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,115.33,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,138,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
TEGADERM 8 X 2,350140,CDM,270,RC,A6257,HCPCS,Outpatient,,,5,3.5,,1.13,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,190.4,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
TEGASORB HYDRO COLLOID DRESSIN,350145,CDM,270,RC,A6238,HCPCS,Outpatient,,,14,9.8,,16.73,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,447.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HYDROGEL WOUND DRESSING 4X6,350150,CDM,270,RC,A6243,HCPCS,Outpatient,,,24,16.8,,9.05,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,22.3,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,68.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
"2"" CONFORM STRETCH BANDAGE",350155,CDM,270,RC,A6263,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,98.46,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,248.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
"3"" CONFORM STRETCH BANDAGE",350160,CDM,270,RC,A6263,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,212.16,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,248.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
PACKING STRIP 1/4 X 5,350165,CDM,270,RC,A6406,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,326.4,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,540.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
TELFA PAD 3X4,350170,CDM,270,RC,A6216,HCPCS,Outpatient,,,3,2.1,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,299.74,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,541.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
TELFA DRESSING 3X8,350175,CDM,270,RC,A6217,HCPCS,Outpatient,,,3,2.1,,0.15,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,299.74,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,541.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
KERLIX GAUZE,350180,CDM,270,RC,A6264,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,540.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
GAUZE SPONGES 12 PLY,350185,CDM,270,RC,A6402,HCPCS,Outpatient,,,4,2.8,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,212.16,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
TEGAGEL WOUND FILLER/OUNCE,350220,CDM,270,RC,A6248,HCPCS,Outpatient,,,8,5.6,,11.93,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
VIASORB WOUND DRESSING 4X6,350225,CDM,270,RC,A6204,HCPCS,Outpatient,,,7,4.9,,4.57,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,76.7,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
BIAFINE 3.3OZ,350230,CDM,270,RC,A6250,HCPCS,Outpatient,,,61,42.7,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
COBAN WRAP,350235,CDM,270,RC,A4460,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,76.7,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
RETRACTOR GOELET 7.5IN DOUBLE,354491,CDM,270,RC,,,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,218.14,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,13,65,,10.4,Percent of Total Billed Charges,65% of Total Billed Charges,15,75,,12,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,12,60,,9.6,Percent of Total Billed Charges,60% of Total Billed Charges,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.08,20.4,,3.26,Percent of Total Billed Charges,20.4% of Total Billed Charges,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,20,,3.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4,15.2,
RETRACTOR FREEMAN RAKE 1.5X7IN,354493,CDM,270,RC,,,Outpatient,,,172,120.4,,,,,,Other,Not Seperately Reimbusable,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,177.89,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,111.8,65,,89.44,Percent of Total Billed Charges,65% of Total Billed Charges,129,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.4,20,,27.52,Percent of Total Billed Charges,20% of Total Billed Charges,103.2,60,,82.56,Percent of Total Billed Charges,60% of Total Billed Charges,35.09,20.4,,28.07,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.09,20.4,,28.07,Percent of Total Billed Charges,20.4% of Total Billed Charges,34.4,20,,27.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.4,20,,27.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,34.4,130.72,
STERILE WATER IRRIGATION 3000,850874,CDM,270,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
"GAD-BASE MR CONTRAST NOS, 1ML",893501,CDM,270,RC,A9579,HCPCS,Outpatient,1,ML,12,8.4,,1.67,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,61.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
"GAD-BASE MR CONTRAST NOS, 1ML,",893504,CDM,270,RC,A9579,HCPCS,Outpatient,1,ML,12,8.4,JW,1.67,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,159.94,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,90.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
STETHOSCOPE SING USE DISPOSABL,893513,CDM,270,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
MULTI LUMEN CV CATHETER KIT 7F,893571,CDM,270,RC,,,Outpatient,,,106,74.2,,,,,,Other,Not Seperately Reimbusable,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,68.9,65,,55.12,Percent of Total Billed Charges,65% of Total Billed Charges,79.5,75,,63.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,20,,16.96,Percent of Total Billed Charges,20% of Total Billed Charges,63.6,60,,50.88,Percent of Total Billed Charges,60% of Total Billed Charges,21.62,20.4,,17.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.62,20.4,,17.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,21.2,20,,16.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.2,20,,16.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.2,80.56,
NASAL CANNULA - LTC,893574,CDM,270,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
"BRIEFS, BARIATRIC",893575,CDM,270,RC,,,Outpatient,,,2,1.4,,,,,,Other,Not Seperately Reimbusable,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,299.2,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1.3,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,1.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,1.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.41,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.4,1.52,
ABSORBENT CO2 LITHOLYME CARTRI,893576,CDM,270,RC,,,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,10.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
BANDAGE NET TUBULAR; SIZE 5 SM,893577,CDM,270,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
BANDAGE NET TUBULAR; SIZE 6 LA,893578,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
INJETAK ADJUSTABLE NEEDLE,893588,CDM,270,RC,,,Outpatient,,,133,93.1,,,,,,Other,Not Seperately Reimbusable,90.44,68,,72.35,Percent of Total Billed Charges,68% of Total Billed Charges,101.08,76,,187.68,Percent of Total Billed Charges,76% of Total Billed Charges,66.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,86.45,65,,69.16,Percent of Total Billed Charges,65% of Total Billed Charges,99.75,75,,79.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.6,20,,21.28,Percent of Total Billed Charges,20% of Total Billed Charges,79.8,60,,63.84,Percent of Total Billed Charges,60% of Total Billed Charges,27.13,20.4,,21.7,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.13,20.4,,21.7,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.6,20,,21.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.6,20,,21.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.6,101.08,
RECTAL TUBE AND FLATUS BAG 24F,893688,CDM,270,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,55.49,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
IV START PACK,72425,CDM,270,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,11.42,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
BLOOD SET-Y-TYPE,210500,CDM,270,RC,Y7507,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,31.55,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
CLY Q SET,210600,CDM,270,RC,Y7507,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,76,,11.97,Percent of Total Billed Charges,76% of Total Billed Charges,25.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,38.76,
EXTENSION SET,210775,CDM,270,RC,,,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,28.83,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.6,65,,12.48,Percent of Total Billed Charges,65% of Total Billed Charges,18,75,,14.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,14.4,60,,11.52,Percent of Total Billed Charges,60% of Total Billed Charges,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.9,20.4,,3.92,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.8,20,,3.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.8,18.24,
INFU-SET-BUTFLY 19GA,210950,CDM,270,RC,Y7507,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,32.1,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
INFUSION-BUTFLY 21GA,211000,CDM,270,RC,Y7507,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,16.32,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,22.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
INFUSION-BUTFLY 23GA,211050,CDM,270,RC,Y7507,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,57.66,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,20.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
INFUSION-BUTFLY 25GA,211100,CDM,270,RC,Y7507,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,28.83,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,26,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
INFUSION-BUTFLY 27GA,211150,CDM,270,RC,Y7507,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,28.83,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
INFUSION-INTER. 21GA,211200,CDM,270,RC,Y7507,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,124.58,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,108.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
INTRACATH 14GA,211250,CDM,270,RC,Y7507,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,111.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
INTRACATH 16GA,211300,CDM,270,RC,Y7507,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
INTRACATH 18GA,211350,CDM,270,RC,Y7507,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
INTRACATH 20GA,211400,CDM,270,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
INTRACATH 22GA,211450,CDM,270,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
INTRACATH 24GA,211455,CDM,270,RC,Y7507,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
IVEX FILTER SET,211500,CDM,270,RC,Y7507,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
I.V. PUMP SETS,211600,CDM,270,RC,Y7507,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,30.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
IV PUMP SET-NITRO,211605,CDM,270,RC,Y7507,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,92.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
IV PUMP SET W FILTER,211610,CDM,270,RC,,,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,78,65,,62.4,Percent of Total Billed Charges,65% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,72,60,,57.6,Percent of Total Billed Charges,60% of Total Billed Charges,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.48,20.4,,19.58,Percent of Total Billed Charges,20.4% of Total Billed Charges,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,20,,19.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24,91.2,
J-LOOP,211640,CDM,270,RC,Y7507,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
PPB W/INLINE FILTER,211700,CDM,270,RC,Y7507,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,7.07,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
VENOSET-ANESTHESIA,211950,CDM,270,RC,Y7507,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,226.3,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
VENOSET SECONDARY PB,212200,CDM,270,RC,,,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,226.3,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
VICRA ADAPTER,212275,CDM,270,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,38.62,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
CAPIO SLIM DELIVERY DEVICE,38825,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3055,2138.5,,,,,,Other,Not Seperately Reimbusable,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,2321.8,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1527.5,50,,61.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1527.5,2321.8,
CAPIO SUTURE,38826,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,110,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
O.R. CASE SET-UP,61300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,240,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
ASSEMBLY KIT,714310,CDM,270,RC,,,Outpatient,,,1796,1257.2,,,,,,Other,Not Seperately Reimbusable,1221.28,68,,977.02,Percent of Total Billed Charges,68% of Total Billed Charges,1364.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,898,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1167.4,65,,933.92,Percent of Total Billed Charges,65% of Total Billed Charges,1347,75,,1077.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,1077.6,60,,862.08,Percent of Total Billed Charges,60% of Total Billed Charges,366.38,20.4,,293.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.38,20.4,,293.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.2,1364.96,
SEVOFLURONE/15MIN,644690,CDM,270,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,86.4,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
STERILE WATER,646170,CDM,270,RC,Y7506,HCPCS,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,22.8,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,15,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,22.8,
SODIUM CHLORIDE 0.9% PAB 50ML,654209,CDM,270,RC,Y7509,HCPCS,Outpatient,50,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,87.55,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,171.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
AEROCHAMBER  #002080,850332,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
AEROCHAMBER MASK-SMALL  #HS811,850333,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
AEROCHAMBER MASK-MEDIUM  #HS81,850334,CDM,270,RC,Y7506,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
AEROFUSE DRAIN BAG  #001561,850335,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
AEROCHAMBER MASK,850336,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
SIDESTREAM NEBULIZER  #002035,850337,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
IPPB CIRCUIT  #1618,850339,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
NELCOR O2 FINGER SENSOR,850360,CDM,270,RC,Y7509,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
AMBU BAGS,850424,CDM,270,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,53.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
AEROSOL MIST-12 HRS,850425,CDM,270,RC,A7506,HCPCS,Outpatient,,,581,406.7,,0.24,100,,,fee schedule,100% Aetna Market fee schedule,395.08,68,,316.06,Percent of Total Billed Charges,68% of Total Billed Charges,441.56,76,,353.25,Percent of Total Billed Charges,76% of Total Billed Charges,290.5,50,,232.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.5,441.56,
AQUA PAK 400ML  #002620,850430,CDM,270,RC,Y7506,HCPCS,Outpatient,400,ML,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
AQUA PAK,850431,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
BIS ELECTRODE O2 SENSOR,850436,CDM,270,RC,Y7506,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
BOUGIE 15 FR,850437,CDM,270,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
CATH N SLEEVE 18FR,850439,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
EASY CAP,850446,CDM,270,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
HEAT MOISTURE EXCHGR,850448,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
INCENTIVE SPIROMETER (SUPPLY),850501,CDM,270,RC,A9284,HCPCS,Outpatient,,,7,4.9,,9.95,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
VENT CIRCUIT,850505,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
MASK-O2,850650,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
NASAL CANNULA,850749,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
NASAL CANNULA-SET UP,850750,CDM,270,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
NASAL CANNULA NEO-NATE  #00261,850751,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
NASAL CANNULA PED  #002662,850752,CDM,270,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
PRESSURE EASY  #C371-292004,850755,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
PALL CIRCUIT FILTER #1605,850770,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
PEDI. CROUP TENT   #81-THS532,850850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
SODIUM CHLORIDE 0.9% 3CC/<  #5,850856,CDM,270,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
S.CHLORIDE 0.9%-15ML  #AL4015,850857,CDM,270,RC,Y7506,HCPCS,Outpatient,5,ML,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
STERI-CATH KIT   #C108-0221,850861,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
RESP ASSIST/15 MIN,850891,CDM,270,RC,Y7506,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
NITROUS OXIDE 0-15 MIN,851200,CDM,270,RC,Y7509,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
OXYGEN 1-5 LITER HRS,851250,CDM,270,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,8.32,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,9.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,7.68,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,2.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,2.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
OXYGEN 1-5 LTR HRS (12 HRS),851275,CDM,270,RC,A9900,HCPCS,Outpatient,,,185,129.5,,,,,,Other,Not Seperately Reimbusable,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,140.6,76,,112.48,Percent of Total Billed Charges,76% of Total Billed Charges,92.5,50,,74,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.5,140.6,
OXYGEN 6 PLUS LT HRS,851300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
OXYGEN 6 PLUS LTR HRS (12 HRS),851325,CDM,270,RC,A9900,HCPCS,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,161.84,68,,129.47,Percent of Total Billed Charges,68% of Total Billed Charges,180.88,76,,144.7,Percent of Total Billed Charges,76% of Total Billed Charges,119,50,,95.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,180.88,
OXYMASK,851351,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
PEAK FLOW-UNIVERSAL  #01801,851382,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
PERCUSSOR (NEO-PINK) #CO95-955,851383,CDM,270,RC,Y7506,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
PERCUSSOR(PED-BLUE)  #CO95-955,851384,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
VENTI-COMP BAG  #1550,851385,CDM,270,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
SPUTUM CUPS,851386,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
MUCUS SPECIMEN TRAPS  #35860,851387,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SIMPLE O2 MASK,851400,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SIMPLE PED O2 MASK  #001262,851450,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
SIMPLE INF. O2 MASK,851500,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NON-REBREATHER MASK,851600,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NON REBREATHER MASK-PED   #105,851601,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
VENTI-MASK ADULT  #001255,851650,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
TRACHEOSTOMY MASK-ADULT  #0012,851700,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
AEROSOL MASK,851750,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
AEROSOL MASK - PED.  #355-220,851800,CDM,270,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
FACE TENT,851850,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
O2 SUPPLY TUBING  #001301,851900,CDM,270,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
E T TUBE HOLDER,852000,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
T-PIECE,852050,CDM,270,RC,Y7506,HCPCS,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
AMBU BAG-PED  #2K8008,852150,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
AMBU BAG-INFANT  #2K8010,852200,CDM,270,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
CONCHAPAK W/COLUMN  #V385-60,852297,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,32.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
DISP. HEAD STRAP  #C73-312106,852298,CDM,270,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
DISP. PROBE-ADULT  #D-25,852299,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,32.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
VENTILATOR CIRC BEAR 1000 #OY1,852300,CDM,270,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
DISP. PROBE -PEDI  #D-20,852302,CDM,270,RC,Y7506,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,32.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
DISP CPAP MASK LG    #C73-4520,852309,CDM,270,RC,Y7506,HCPCS,Outpatient,,,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
DISTILLED WATER-GAL,852310,CDM,270,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
BI-PAP CIRCUIT,852316,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
HOLTER KIT   #HKLL5109V60,852317,CDM,270,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
CONTOUR NASAL MASK  #C73-31210,852318,CDM,270,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
CPAP/BIPAP MASK,852320,CDM,270,RC,Y7506,HCPCS,Outpatient,,,62,43.4,,,,,,Other,Not Seperately Reimbusable,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
CONTINUOUS NEB. CIRCUITS,852363,CDM,270,RC,Y7506,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
IPRATROPIUM/ALBUTEROL INH SOL,852366,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
HYPERTONIC SALINE(7% NACL) INH,852367,CDM,270,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
SUPP/XEROFORM DRESS,200100,CDM,270,RC,A4205,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUPP/CATH. STRAIGHT,200200,CDM,270,RC,A4351,HCPCS,Outpatient,,,31,21.7,,1.33,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
SUPP/ACE BANDAGE,200300,CDM,270,RC,A4460,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUPP/ALUMINUM CRUTCHES,200400,CDM,270,RC,E0114,HCPCS,Outpatient,,,23,16.1,,5.87,100,,,fee schedule,100% Aetna Market fee schedule,15.64,68,,12.51,Percent of Total Billed Charges,68% of Total Billed Charges,17.48,76,,13.98,Percent of Total Billed Charges,76% of Total Billed Charges,11.5,50,,9.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.5,17.48,
SUPP/KERLIX,200800,CDM,270,RC,A4203,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SUPP/TAPE - ROLL,200900,CDM,270,RC,A4450,HCPCS,Outpatient,,,3,2.1,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUPP/DERMIFORM TAPE,201200,CDM,270,RC,A4454,HCPCS,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
SUPP/SUTURE REM TRAY,201300,CDM,270,RC,A4550,HCPCS,Outpatient,,,26,18.2,,11.65,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
SUPP/LACERATION TRAY,201500,CDM,270,RC,A4550,HCPCS,Outpatient,,,27,18.9,,11.65,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
SUPP/4X4 STERILE 1PK,201600,CDM,270,RC,A6402,HCPCS,Outpatient,,,9,6.3,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SUPP/SLING,201700,CDM,270,RC,A4565,HCPCS,Outpatient,,,16,11.2,,5.65,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SUPP/3X3 NONSTERILE,201800,CDM,270,RC,A4649,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUPP/COLD PACK,201900,CDM,270,RC,A9273,HCPCS,Outpatient,,,11,7.7,,4.62,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
SUPP/STERI-STRIPS 1/4IN,202800,CDM,270,RC,A6263,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SUPP/STERILE GLOVES,210100,CDM,270,RC,A4927,HCPCS,Outpatient,,,2,1.4,,1.58,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
"SUPP/IODOFORM 1/4""",259100,CDM,270,RC,A4450,HCPCS,Outpatient,,,10,7,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
"SUPP/IODOFORM 2""",259200,CDM,270,RC,A6213,HCPCS,Outpatient,,,12,8.4,,8.49,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
SUPP/BETADINE SWAB,260900,CDM,270,RC,A4247,HCPCS,Outpatient,,,2,1.4,,1.78,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
"SUPP/KLING 2""",261800,CDM,270,RC,A6442,HCPCS,Outpatient,,,4,2.8,,0.11,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SUPP/TELFA PADS 4X4,262000,CDM,270,RC,A6217,HCPCS,Outpatient,,,2,1.4,,0.15,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
SUPP/TEGADERM 4X4,265200,CDM,270,RC,A6260,HCPCS,Outpatient,,,1,0.7,,0.39,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,0.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
SUPP/AQUACEL AG EXT 4X5,265300,CDM,270,RC,A6196,HCPCS,Outpatient,,,12,8.4,,5.41,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
SUPP/DRSG TRANSPARENT LG,1925000,CDM,270,RC,A6257,HCPCS,Outpatient,,,5,3.5,,1.13,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
SUPP/CAST SUPPLIES,2005000,CDM,270,RC,A4580,HCPCS,Outpatient,,,18,12.6,,9,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,13.68,
SUPP/COBAN WRAP,2030000,CDM,270,RC,A6453,HCPCS,Outpatient,,,8,5.6,,0.46,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
SUPP/SPLINT ALUMINUM FINGER,2059000,CDM,270,RC,A4570,HCPCS,Outpatient,,,7,4.9,,6.91,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
SUPP/CHEMO LATEX GLOVES,2062000,CDM,270,RC,A9270,HCPCS,Outpatient,,,3,2.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
SUPP/CHEMO PLUS PADS,2063000,CDM,270,RC,A9270,HCPCS,Outpatient,,,4,2.8,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SUPP/SPLASH RESISTANT GOWN,2064000,CDM,270,RC,A9270,HCPCS,Outpatient,,,7,4.9,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
SUPP/MASK WITH FACE SHIELD,2065000,CDM,270,RC,A9270,HCPCS,Outpatient,,,4,2.8,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
SUPP/DERMABOND,2624000,CDM,270,RC,G0168,HCPCS,Outpatient,,,44,30.8,,14.05,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,28.52,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
MONITOR ELECT REDDOT,41150,CDM,271,RC,,,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,26,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,30,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,24,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,8.16,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.16,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,8,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8,30.4,
AEROSOL MIST SETUP,850410,CDM,271,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
CROUP TENT INITIATION,850700,CDM,271,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
INF OXY-HOOD SET-UP,852250,CDM,271,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
OXYGEN THERAPY; SET-UP,852331,CDM,271,RC,,,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,87.1,65,,69.68,Percent of Total Billed Charges,65% of Total Billed Charges,100.5,75,,80.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.8,20,,21.44,Percent of Total Billed Charges,20% of Total Billed Charges,80.4,60,,64.32,Percent of Total Billed Charges,60% of Total Billed Charges,27.34,20.4,,21.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.34,20.4,,21.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,26.8,20,,21.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.8,20,,21.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.8,101.84,
NASOPHARYNGEAL AIRWAY,60376,CDM,272,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
AUQUA CELL DRESSING,17570,CDM,272,RC,Y7509,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.68,Other,Not Seperately Reimbusable,,,,5.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.47,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
CALC ALGINATE DRSG,17828,CDM,272,RC,,,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
WOUND DRESSING  8 X 12,17838,CDM,272,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
PETROLEUM GAUZE 3X9,19900,CDM,272,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,1494.48,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,1724.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1379.52,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,469.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,469.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
SILVER CELL NON ADHERENT,20660,CDM,272,RC,Y7509,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ULCER DR-ULTEC 4X4,21908,CDM,272,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
TEGADERM/PAD 6 X 6,21935,CDM,272,RC,,,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.15,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,8.25,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,6.6,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,2.24,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.24,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.2,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.2,8.36,
AQUACEL AG EXT 4X5,30715,CDM,272,RC,A6196,HCPCS,Outpatient,,,12,8.4,,5.41,100,,,fee schedule,100% Aetna Market fee schedule,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
DIGITEX SUTURE,31310,CDM,272,RC,,,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.7,65,,9.88,Percent of Total Billed Charges,65% of Total Billed Charges,28.5,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,22.8,60,,9.12,Percent of Total Billed Charges,60% of Total Billed Charges,7.75,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.75,20.4,,3.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.6,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.6,20,,3.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.6,28.88,
VENTILATION TUBES-MEDTRONIC (E,34900,CDM,272,RC,Y7509,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
UPHOLD LITE MESH KIT,55900,CDM,272,RC,,,Outpatient,,,3016,2111.2,,,,,,Other,Not Seperately Reimbusable,2050.88,68,,1640.7,Percent of Total Billed Charges,68% of Total Billed Charges,2292.16,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1508,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,1960.4,65,,234,Percent of Total Billed Charges,65% of Total Billed Charges,2262,75,,270,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.2,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,1809.6,60,,216,Percent of Total Billed Charges,60% of Total Billed Charges,615.26,20.4,,73.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,615.26,20.4,,73.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,603.2,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,603.2,20,,72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,603.2,2292.16,
"UROSTOMY/POUCH/DRAIN 2 1/4 9""L",57251,CDM,272,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
UROSTOMY WAFER/BARRIER SKIN FL,57252,CDM,272,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
ELECT/SURG. GRND PAD,58950,CDM,272,RC,,,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,11.7,65,,9.36,Percent of Total Billed Charges,65% of Total Billed Charges,13.5,75,,10.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,10.8,60,,8.64,Percent of Total Billed Charges,60% of Total Billed Charges,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.67,20.4,,2.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.6,20,,2.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.6,13.68,
MASK-DISP ANESTHESIA,61100,CDM,272,RC,,,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,13.65,65,,1.56,Percent of Total Billed Charges,65% of Total Billed Charges,15.75,75,,1.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,12.6,60,,1.44,Percent of Total Billed Charges,60% of Total Billed Charges,4.28,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.28,20.4,,0.49,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.2,20,,0.48,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.2,15.96,
BLADDER EVAC,61213,CDM,272,RC,Y7506,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,70.68,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,46.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.2,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.5,70.68,
BLADDER SLING SYSTEM,61215,CDM,272,RC,Y7509,HCPCS,Outpatient,,,1694,1185.8,,,,,,Other,Not Seperately Reimbusable,1151.92,68,,921.54,Percent of Total Billed Charges,68% of Total Billed Charges,1287.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,847,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,153.92,Other,Not Seperately Reimbusable,,,,177.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.36,Other,Not Seperately Reimbusable,,,,142.08,Other,Not Seperately Reimbusable,,,,48.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48.3,Other,Not Seperately Reimbusable,,,,47.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.36,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,847,1287.44,
STIMULATION TEST LEAD,61229,CDM,272,RC,A4290,HCPCS,Outpatient,,,127,88.9,,57.67,100,,,fee schedule,100% Aetna Market fee schedule,86.36,68,,69.09,Percent of Total Billed Charges,68% of Total Billed Charges,96.52,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,63.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.8,Other,Not Seperately Reimbusable,,,,24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.53,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.5,96.52,
PODIATRY SCREW SET,61420,CDM,272,RC,Y7509,HCPCS,Outpatient,,,550,385,,,,,,Other,Not Seperately Reimbusable,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,418,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,275,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,418,
PORT-A-CATH,61428,CDM,272,RC,Y7509,HCPCS,Outpatient,,,1598,1118.6,,,,,,Other,Not Seperately Reimbusable,1086.64,68,,869.31,Percent of Total Billed Charges,68% of Total Billed Charges,1214.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,799,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,799,1214.48,
REBREATHING CIRCUIT,61550,CDM,272,RC,,,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,546.59,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,359.6,Percent of Total Billed Charges,50% of Total Billed Charges,22.75,65,,17.16,Percent of Total Billed Charges,65% of Total Billed Charges,26.25,75,,19.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,178.64,Other,Not Seperately Reimbusable,,,,191.4,Other,Not Seperately Reimbusable,7,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,21,60,,15.84,Percent of Total Billed Charges,60% of Total Billed Charges,7.14,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.14,20.4,,5.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,7,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,20,,5.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7,26.6,
SUCTION LINERS,62300,CDM,272,RC,,,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,54.72,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,10.4,65,,37.96,Percent of Total Billed Charges,65% of Total Billed Charges,12,75,,43.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,3.2,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,9.6,60,,35.04,Percent of Total Billed Charges,60% of Total Billed Charges,3.26,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.26,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.2,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.2,12.16,
TISSUE CONNECTIVE-HUMAN,62780,CDM,272,RC,Y7509,HCPCS,Outpatient,,,1779,1245.3,,,,,,Other,Not Seperately Reimbusable,1209.72,68,,967.78,Percent of Total Billed Charges,68% of Total Billed Charges,1352.04,76,,27.36,Percent of Total Billed Charges,76% of Total Billed Charges,889.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,889.5,1352.04,
TISSUE CONNECTIVE-NON HUMAN,62790,CDM,272,RC,Y7509,HCPCS,Outpatient,,,497,347.9,,,,,,Other,Not Seperately Reimbusable,337.96,68,,270.37,Percent of Total Billed Charges,68% of Total Billed Charges,377.72,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,248.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,240.24,Other,Not Seperately Reimbusable,,,,277.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,73.92,Other,Not Seperately Reimbusable,,,,221.76,Other,Not Seperately Reimbusable,,,,75.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,75.4,Other,Not Seperately Reimbusable,,,,73.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,73.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.5,377.72,
MESH ELEVATE KIT,62926,CDM,272,RC,,,Outpatient,,,2585,1809.5,,,,,,Other,Not Seperately Reimbusable,1757.8,68,,1406.24,Percent of Total Billed Charges,68% of Total Billed Charges,1964.6,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,1292.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,1680.25,65,,42.64,Percent of Total Billed Charges,65% of Total Billed Charges,1938.75,75,,49.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,47.6,Other,Not Seperately Reimbusable,,,,51,Other,Not Seperately Reimbusable,517,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,1551,60,,39.36,Percent of Total Billed Charges,60% of Total Billed Charges,527.34,20.4,,13.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,527.34,20.4,,13.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,517,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,517,20,,13.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,517,1964.6,
VAGITRAC DRAPE KIT,63000,CDM,272,RC,,,Outpatient,,,146,102.2,,,,,,Other,Not Seperately Reimbusable,99.28,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,110.96,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,73,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,94.9,65,,1.04,Percent of Total Billed Charges,65% of Total Billed Charges,109.5,75,,1.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,29.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,87.6,60,,0.96,Percent of Total Billed Charges,60% of Total Billed Charges,29.78,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.78,20.4,,0.33,Percent of Total Billed Charges,20.4% of Total Billed Charges,29.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.2,20,,0.32,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,29.2,110.96,
DERMAGINATE/AG,63380,CDM,272,RC,A6196,HCPCS,Outpatient,,,6,4.2,,5.41,100,,,fee schedule,100% Aetna Market fee schedule,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.4,Other,Not Seperately Reimbusable,,,,234,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
SUTURE,63850,CDM,272,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,6.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
SYRINGE 5CC,70350,CDM,272,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,635.39,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,336,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,711.76,Other,Not Seperately Reimbusable,,,,762.6,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
SYRINGE 20CC,70375,CDM,272,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,836.67,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
PARIETEX COMPOSITE 8X16,72881,CDM,272,RC,A6203,HCPCS,Outpatient,,,1191,833.7,,2.47,100,,,fee schedule,100% Aetna Market fee schedule,809.88,68,,647.9,Percent of Total Billed Charges,68% of Total Billed Charges,905.16,76,,208.9,Percent of Total Billed Charges,76% of Total Billed Charges,595.5,50,,211.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,595.5,905.16,
PARIETEX COMPOSITE 14.5X11,72882,CDM,272,RC,A6205,HCPCS,Outpatient,,,4209,2946.3,,7.5,100,,,fee schedule,100% Aetna Market fee schedule,2862.12,68,,2289.7,Percent of Total Billed Charges,68% of Total Billed Charges,3198.84,76,,364.48,Percent of Total Billed Charges,76% of Total Billed Charges,2104.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2104.5,3198.84,
PARIETEX COMPOSITE 10X8,72883,CDM,272,RC,A6204,HCPCS,Outpatient,,,1927,1348.9,,4.57,100,,,fee schedule,100% Aetna Market fee schedule,1310.36,68,,1048.29,Percent of Total Billed Charges,68% of Total Billed Charges,1464.52,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,963.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,963.5,1464.52,
CIRCUIT NONINV EXHL PORT PROX,73587,CDM,272,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
FULGURATING ELECT LG TIP 105CM,73588,CDM,272,RC,,,Outpatient,,,236,165.2,,,,,,Other,Not Seperately Reimbusable,160.48,68,,128.38,Percent of Total Billed Charges,68% of Total Billed Charges,179.36,76,,857.34,Percent of Total Billed Charges,76% of Total Billed Charges,118,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,153.4,65,,122.72,Percent of Total Billed Charges,65% of Total Billed Charges,177,75,,141.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,141.6,60,,113.28,Percent of Total Billed Charges,60% of Total Billed Charges,48.14,20.4,,38.51,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.14,20.4,,38.51,Percent of Total Billed Charges,20.4% of Total Billed Charges,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.2,179.36,
2-WAY CATH.18FR 5CC,74950,CDM,272,RC,Y7506,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,122,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,72.8,Other,Not Seperately Reimbusable,,,,78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
2-WAY CATH.22FR 30CC,75300,CDM,272,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,173.54,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,84,Other,Not Seperately Reimbusable,,,,90,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
2-WAY CATH.24FR 30CC,75350,CDM,272,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,91.39,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,258.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,98.56,Other,Not Seperately Reimbusable,,,,105.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
3-WAY CATH.16FR 30CC,75650,CDM,272,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,299.2,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.44,Other,Not Seperately Reimbusable,,,,164.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
CATH TRAY W/O FOLEY,76300,CDM,272,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,81.6,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,282.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,204.96,Other,Not Seperately Reimbusable,,,,219.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
CATH.TRAY 18FR BAG-T,76400,CDM,272,RC,Y7506,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,161.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,41.44,Other,Not Seperately Reimbusable,,,,44.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,56.24,
TEXAS CATHETER,76800,CDM,272,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,55.44,Other,Not Seperately Reimbusable,,,,59.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
OPTIFOAM NON-ADHESIVE 6X6,79000,CDM,272,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,240,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,66.08,Other,Not Seperately Reimbusable,,,,70.8,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
OPTIFOAM GENTLE BORDER 4X4,79001,CDM,272,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,220.4,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
PRO TOWEL 2PLY BLU 13X18,79002,CDM,272,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,220.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
BULKEE II GAUZE 4.5 X 4 YD STR,79003,CDM,272,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
CAUTERY HI-TEMP FINE,79004,CDM,272,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,165.92,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,156,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
TUBIFAST BLU GL 3 1/8 X 33',79005,CDM,272,RC,,,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,68.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.9,65,,13.52,Percent of Total Billed Charges,65% of Total Billed Charges,19.5,75,,15.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,15.6,60,,12.48,Percent of Total Billed Charges,60% of Total Billed Charges,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.3,20.4,,4.24,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.2,20,,4.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.2,19.76,
"TAPE MEASURE PAPER INF 36"" LF",79006,CDM,272,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
CLEANER ENZYMATIC PREPZYME,79007,CDM,272,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
SCISSOR BANDAGE UTILITY 7 1/2,79008,CDM,272,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
SULFOLYSER 3 X 500ML,79009,CDM,272,RC,,,Outpatient,500,ML,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,31.16,
CELLPACK 20L,79010,CDM,272,RC,,,Outpatient,,,45,31.5,,,,,,Other,Not Seperately Reimbusable,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,34.2,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,22.5,50,,314,Percent of Total Billed Charges,50% of Total Billed Charges,29.25,65,,23.4,Percent of Total Billed Charges,65% of Total Billed Charges,33.75,75,,27,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,27,60,,21.6,Percent of Total Billed Charges,60% of Total Billed Charges,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.18,20.4,,7.34,Percent of Total Billed Charges,20.4% of Total Billed Charges,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,20,,7.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9,34.2,
STROMATOLYSER 4DS 42ML,79011,CDM,272,RC,,,Outpatient,442,ML,135,94.5,,,,,,Other,Not Seperately Reimbusable,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,46.24,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,87.75,65,,70.2,Percent of Total Billed Charges,65% of Total Billed Charges,101.25,75,,81,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,81,60,,64.8,Percent of Total Billed Charges,60% of Total Billed Charges,27.54,20.4,,22.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27.54,20.4,,22.03,Percent of Total Billed Charges,20.4% of Total Billed Charges,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,20,,21.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,27,102.6,
MEPILEX FOAM ANTI MICRO 8X8,79012,CDM,272,RC,,,Outpatient,,,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,47.45,65,,37.96,Percent of Total Billed Charges,65% of Total Billed Charges,54.75,75,,43.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,43.8,60,,35.04,Percent of Total Billed Charges,60% of Total Billed Charges,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.89,20.4,,11.91,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,20,,11.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.6,55.48,
DERMA WOUND CLEANSER 4 OZ,79013,CDM,272,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,46.24,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
SALINE INHALATION SOL 0.9% 15M,79014,CDM,272,RC,,,Outpatient,,,1,0.7,,,,,,Other,Not Seperately Reimbusable,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,351.97,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,0.65,65,,0.52,Percent of Total Billed Charges,65% of Total Billed Charges,0.75,75,,0.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,0.6,60,,0.48,Percent of Total Billed Charges,60% of Total Billed Charges,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,20.4,,0.16,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.2,20,,0.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.2,0.76,
WND AQUACEL AG X HYDROFIBER 6',79015,CDM,272,RC,,,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,303.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
COMPRSN COFLEX TLC 2LYR XLNG,79016,CDM,272,RC,,,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,11.05,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,10.2,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.47,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.4,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3.4,12.92,
URETHRAL CATHETER TRAY,350020,CDM,272,RC,A4311,HCPCS,Outpatient,,,25,17.5,,10.76,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,142.53,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
URINARY LEG BAG,350105,CDM,272,RC,A4358,HCPCS,Outpatient,,,10,7,,4.33,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,89.76,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
URINARY DRAINAGE BAG,350110,CDM,272,RC,A4357,HCPCS,Outpatient,,,27,18.9,,7.09,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,219.78,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,138,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
STER TEGADERM 4X4 3/4 DRESSING,350221,CDM,272,RC,A6257,HCPCS,Outpatient,,,9,6.3,,1.13,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
SILVERLON CA 4X8,350255,CDM,272,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
SCOTCH QCK 3X15FT DBL SIDE FLT,630609,CDM,272,RC,,,Outpatient,,,91,63.7,,,,,,Other,Not Seperately Reimbusable,61.88,68,,49.5,Percent of Total Billed Charges,68% of Total Billed Charges,69.16,76,,177.89,Percent of Total Billed Charges,76% of Total Billed Charges,45.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.15,65,,47.32,Percent of Total Billed Charges,65% of Total Billed Charges,68.25,75,,54.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,54.6,60,,43.68,Percent of Total Billed Charges,60% of Total Billed Charges,18.56,20.4,,14.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.56,20.4,,14.85,Percent of Total Billed Charges,20.4% of Total Billed Charges,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.2,20,,14.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.2,69.16,
SCOTCH QCK 4X15FT DBL SIDE FLT,630612,CDM,272,RC,,,Outpatient,,,104,72.8,,,,,,Other,Not Seperately Reimbusable,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,79.04,76,,221.95,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.6,65,,54.08,Percent of Total Billed Charges,65% of Total Billed Charges,78,75,,62.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,62.4,60,,49.92,Percent of Total Billed Charges,60% of Total Billed Charges,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,21.22,20.4,,16.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,20,,16.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,20.8,79.04,
SCOTCH QCK 5X15FT DBL SIDE FLT,630615,CDM,272,RC,,,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,98.8,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,84.5,65,,67.6,Percent of Total Billed Charges,65% of Total Billed Charges,97.5,75,,78,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,78,60,,62.4,Percent of Total Billed Charges,60% of Total Billed Charges,26.52,20.4,,21.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26.52,20.4,,21.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,26,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,20,,20.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,26,98.8,
OSMOLITE 1.5-1000ML,635002,CDM,272,RC,B4150,HCPCS,Outpatient,1000,ML,9,6.3,,0.34,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
DECOMP NDL KIT 14GA X3 1/4 IN,736520,CDM,272,RC,73652,HCPCS,Outpatient,,,21,14.7,,,,,,Other,Not Seperately Reimbusable,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
RADIOFREQ CURVED CANNULA 5CM,893506,CDM,272,RC,,,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,223.58,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
RADIOFREQ CURVED CANNULA 15CM,893507,CDM,272,RC,,,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,367.2,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.15,65,,16.12,Percent of Total Billed Charges,65% of Total Billed Charges,23.25,75,,18.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,18.6,60,,14.88,Percent of Total Billed Charges,60% of Total Billed Charges,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.32,20.4,,5.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.2,20,,4.96,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6.2,23.56,
RADIOFREQ CURVED CANNULA 10CM,893508,CDM,272,RC,,,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,55.49,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27.36,
TUOHY NEEDLE 18G X 6IN W/ WING,893509,CDM,272,RC,,,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,55.49,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,7.8,65,,6.24,Percent of Total Billed Charges,65% of Total Billed Charges,9,75,,7.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,7.2,60,,5.76,Percent of Total Billed Charges,60% of Total Billed Charges,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.45,20.4,,1.96,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.4,20,,1.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.4,9.12,
TUOHY NEEDLE 20G X 6IN W/ WING,893510,CDM,272,RC,,,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,332.38,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.5,65,,5.2,Percent of Total Billed Charges,65% of Total Billed Charges,7.5,75,,6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,6,60,,4.8,Percent of Total Billed Charges,60% of Total Billed Charges,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.04,20.4,,1.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,20,,1.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2,7.6,
TUOHY NEEDLE 20G X 3.5IN W/ WI,893511,CDM,272,RC,,,Outpatient,,,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,5.85,65,,4.68,Percent of Total Billed Charges,65% of Total Billed Charges,6.75,75,,5.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,5.4,60,,4.32,Percent of Total Billed Charges,60% of Total Billed Charges,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.84,20.4,,1.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.8,20,,1.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.8,6.84,
PRIM PLUMSET PE LND TUBING 107,893645,CDM,272,RC,73602,HCPCS,Outpatient,,,12,8.4,,,,,,Other,Not Seperately Reimbusable,8.16,68,,6.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.12,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,6,50,,18.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6,9.12,
NITROGLYCERIN PLUMSET,12960,CDM,272,RC,Y7509,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
PCA TUBING LONG/INJECTOR,14866,CDM,272,RC,Y7509,HCPCS,Outpatient,,,18,12.6,,,,,,Other,Not Seperately Reimbusable,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,13.68,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,9,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9,13.68,
MESH 8X8,61206,CDM,272,RC,Y7509,HCPCS,Outpatient,,,219,153.3,,,,,,Other,Not Seperately Reimbusable,148.92,68,,119.14,Percent of Total Billed Charges,68% of Total Billed Charges,166.44,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,109.5,50,,160,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.5,166.44,
MEDIHONEY 1.5 OZ TUBE,70274,CDM,272,RC,,,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,19,
CL RESERVOIR,715410,CDM,272,RC,,,Outpatient,,,4214,2949.8,,,,,,Other,Not Seperately Reimbusable,2865.52,68,,2292.42,Percent of Total Billed Charges,68% of Total Billed Charges,3202.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2107,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,2739.1,65,,2191.28,Percent of Total Billed Charges,65% of Total Billed Charges,3160.5,75,,2528.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,842.8,20,,674.24,Percent of Total Billed Charges,20% of Total Billed Charges,2528.4,60,,2022.72,Percent of Total Billed Charges,60% of Total Billed Charges,859.66,20.4,,687.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.66,20.4,,687.73,Percent of Total Billed Charges,20.4% of Total Billed Charges,842.8,20,,674.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,842.8,20,,674.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,842.8,3202.64,
EXTERNAL TRIAL STIMULATOR,725440,CDM,272,RC,,,Outpatient,,,440,308,,,,,,Other,Not Seperately Reimbusable,299.2,68,,239.36,Percent of Total Billed Charges,68% of Total Billed Charges,334.4,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,220,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,286,65,,228.8,Percent of Total Billed Charges,65% of Total Billed Charges,330,75,,264,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88,20,,70.4,Percent of Total Billed Charges,20% of Total Billed Charges,264,60,,211.2,Percent of Total Billed Charges,60% of Total Billed Charges,89.76,20.4,,71.81,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,89.76,20.4,,71.81,Percent of Total Billed Charges,20.4% of Total Billed Charges,88,20,,70.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88,20,,70.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,88,334.4,
NARROW BASE AR TIP EXT,728180,CDM,272,RC,,,Outpatient,,,868,607.6,,,,,,Other,Not Seperately Reimbusable,590.24,68,,472.19,Percent of Total Billed Charges,68% of Total Billed Charges,659.68,76,,632.93,Percent of Total Billed Charges,76% of Total Billed Charges,434,50,,280.8,Percent of Total Billed Charges,50% of Total Billed Charges,564.2,65,,451.36,Percent of Total Billed Charges,65% of Total Billed Charges,651,75,,520.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.6,20,,138.88,Percent of Total Billed Charges,20% of Total Billed Charges,520.8,60,,416.64,Percent of Total Billed Charges,60% of Total Billed Charges,177.07,20.4,,141.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,177.07,20.4,,141.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,173.6,20,,138.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.6,20,,138.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,173.6,659.68,
FULG ELECTRDE LNG 3FR X 105CM,735880,CDM,272,RC,,,Outpatient,,,236,165.2,,,,,,Other,Not Seperately Reimbusable,160.48,68,,128.38,Percent of Total Billed Charges,68% of Total Billed Charges,179.36,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,118,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,153.4,65,,122.72,Percent of Total Billed Charges,65% of Total Billed Charges,177,75,,141.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,141.6,60,,113.28,Percent of Total Billed Charges,60% of Total Billed Charges,48.14,20.4,,38.51,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,48.14,20.4,,38.51,Percent of Total Billed Charges,20.4% of Total Billed Charges,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.2,20,,37.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,47.2,179.36,
COLOPLAST ASSEMBLY KIT,737880,CDM,272,RC,,,Outpatient,,,1796,1257.2,,,,,,Other,Not Seperately Reimbusable,1221.28,68,,977.02,Percent of Total Billed Charges,68% of Total Billed Charges,1364.96,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,898,50,,1652,Percent of Total Billed Charges,50% of Total Billed Charges,1167.4,65,,933.92,Percent of Total Billed Charges,65% of Total Billed Charges,1347,75,,1077.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,1077.6,60,,862.08,Percent of Total Billed Charges,60% of Total Billed Charges,366.38,20.4,,293.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,366.38,20.4,,293.1,Percent of Total Billed Charges,20.4% of Total Billed Charges,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,359.2,20,,287.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,359.2,1364.96,
SCOPOLAMINE 1.5MG,644000,CDM,272,RC,Y7506,HCPCS,Outpatient,15,ME,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
DRAIN POUCH,12405,CDM,274,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,28.08,Other,Not Seperately Reimbusable,,,,32.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,25.92,Other,Not Seperately Reimbusable,,,,8.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.82,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,3.8,
CATHETER-SUPRAPUBIC/CYSTOSCOPI,35825,CDM,274,RC,C2627,HCPCS,Outpatient,,,1144,800.8,,73.04,100,,,fee schedule,100% Aetna Market fee schedule,777.92,68,,622.34,Percent of Total Billed Charges,68% of Total Billed Charges,869.44,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,572,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,572,869.44,
NEPHROSTOMY URINARY DRAIN BAG,56825,CDM,274,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
UROSTOMY BAGS 1 3/4,57260,CDM,274,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13,Other,Not Seperately Reimbusable,,,,15,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
SPAR C SLING,62075,CDM,274,RC,Y7509,HCPCS,Outpatient,,,1472,1030.4,,,,,,Other,Not Seperately Reimbusable,1000.96,68,,800.77,Percent of Total Billed Charges,68% of Total Billed Charges,1118.72,76,,1171.62,Percent of Total Billed Charges,76% of Total Billed Charges,736,50,,770.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,94.08,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736,1118.72,
STRESS INCONTINENCE SLING,54675,CDM,274,RC,C1771,HCPCS,Outpatient,,,2303,1612.1,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,1566.04,68,,1252.83,Percent of Total Billed Charges,68% of Total Billed Charges,1750.28,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1151.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1151.5,1750.28,
O BTRYX SLING,61262,CDM,274,RC,C1771,HCPCS,Outpatient,,,2303,1612.1,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,1566.04,68,,1252.83,Percent of Total Billed Charges,68% of Total Billed Charges,1750.28,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1151.5,50,,1022.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1151.5,1750.28,
SYNTHETIC IMPLANTED BULKING AG,893558,CDM,274,RC,L8606,HCPCS,Outpatient,,,2300,1610,,102.89,100,,,fee schedule,100% Aetna Market fee schedule,1564,68,,1251.2,Percent of Total Billed Charges,68% of Total Billed Charges,1748,76,,421.34,Percent of Total Billed Charges,76% of Total Billed Charges,1150,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1150,1748,
INTRAOCULAR LENS,60425,CDM,276,RC,Y7506,HCPCS,Outpatient,,,799,559.3,,,,,,Other,Not Seperately Reimbusable,543.32,68,,434.66,Percent of Total Billed Charges,68% of Total Billed Charges,607.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,399.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.5,607.24,
AXIS DERMIS TISSUE 6X12 CM,30675,CDM,278,RC,C1762,HCPCS,Outpatient,,,5086,3560.2,,2178.09,100,,,fee schedule,100% Aetna Market fee schedule,3458.48,68,,2766.78,Percent of Total Billed Charges,68% of Total Billed Charges,3865.36,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,2543,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2543,3865.36,
DIRECT FIX MESH ANTERIOR,31400,CDM,278,RC,C1781,HCPCS,Outpatient,,,1434,1003.8,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,975.12,68,,780.1,Percent of Total Billed Charges,68% of Total Billed Charges,1089.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,717,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.12,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,2.88,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.98,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,717,1089.84,
ACCESS SHEATH,57414,CDM,278,RC,C1766,HCPCS,Outpatient,,,460,322,,137.47,100,,,fee schedule,100% Aetna Market fee schedule,312.8,68,,250.24,Percent of Total Billed Charges,68% of Total Billed Charges,349.6,76,,86.34,Percent of Total Billed Charges,76% of Total Billed Charges,230,50,,56.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230,349.6,
ANTERIOR PROLAPSE REPAIR SYS,57799,CDM,278,RC,C1763,HCPCS,Outpatient,,,2741,1918.7,,408.19,100,,,fee schedule,100% Aetna Market fee schedule,1863.88,68,,1491.1,Percent of Total Billed Charges,68% of Total Billed Charges,2083.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1370.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,57.72,Other,Not Seperately Reimbusable,,,,66.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,53.28,Other,Not Seperately Reimbusable,,,,18.11,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.11,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1370.5,2083.16,
COLOPLAST ARIS SLING,58324,CDM,278,RC,C1771,HCPCS,Outpatient,,,927,648.9,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,630.36,68,,504.29,Percent of Total Billed Charges,68% of Total Billed Charges,704.52,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,463.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,463.5,704.52,
COLOPLAST SHEATH,58329,CDM,278,RC,C1766,HCPCS,Outpatient,,,196,137.2,,137.47,100,,,fee schedule,100% Aetna Market fee schedule,133.28,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,148.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,98,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,8.84,Other,Not Seperately Reimbusable,,,,10.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,8.16,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.78,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.72,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98,148.96,
GEMINI BASKET,59935,CDM,278,RC,C1773,HCPCS,Outpatient,,,378,264.6,,70,100,,,fee schedule,100% Aetna Market fee schedule,257.04,68,,205.63,Percent of Total Billed Charges,68% of Total Billed Charges,287.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,189,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,83.72,Other,Not Seperately Reimbusable,,,,96.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.76,Other,Not Seperately Reimbusable,,,,77.28,Other,Not Seperately Reimbusable,,,,26.27,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.27,Other,Not Seperately Reimbusable,,,,25.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,287.28,
GUIDANCE WIRE,59949,CDM,278,RC,C1769,HCPCS,Outpatient,,,186,130.2,,55.13,100,,,fee schedule,100% Aetna Market fee schedule,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,141.36,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,202.8,Other,Not Seperately Reimbusable,,,,234,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,187.2,Other,Not Seperately Reimbusable,,,,63.65,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.65,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,62.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93,141.36,
INTRODUCER SHEATH,60427,CDM,278,RC,Y7509,HCPCS,Outpatient,,,401,280.7,,,,,,Other,Not Seperately Reimbusable,272.68,68,,218.14,Percent of Total Billed Charges,68% of Total Billed Charges,304.76,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,200.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.5,304.76,
LEAD NEUROSTIMULATOR,60755,CDM,278,RC,C1778,HCPCS,Outpatient,,,4550,3185,,582.6,100,,,fee schedule,100% Aetna Market fee schedule,3094,68,,2475.2,Percent of Total Billed Charges,68% of Total Billed Charges,3458,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,2275,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2275,3458,
TESTICULAR PROSTHESIS,61222,CDM,278,RC,,,Outpatient,,,2340,1638,,,,,,Other,Not Seperately Reimbusable,1591.2,68,,1272.96,Percent of Total Billed Charges,68% of Total Billed Charges,1778.4,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,1170,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,1521,65,,8.84,Percent of Total Billed Charges,65% of Total Billed Charges,1755,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,1404,60,,8.16,Percent of Total Billed Charges,60% of Total Billed Charges,477.36,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,477.36,20.4,,2.78,Percent of Total Billed Charges,20.4% of Total Billed Charges,468,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,468,20,,2.72,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,468,1778.4,
POSTERIOR PROLAPSE REPAIR SYS,61424,CDM,278,RC,C1763,HCPCS,Outpatient,,,2330,1631,,408.19,100,,,fee schedule,100% Aetna Market fee schedule,1584.4,68,,1267.52,Percent of Total Billed Charges,68% of Total Billed Charges,1770.8,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1165,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1165,1770.8,
SCREW SET,61875,CDM,278,RC,C1713,HCPCS,Outpatient,,,1457,1019.9,,317.26,100,,,fee schedule,100% Aetna Market fee schedule,990.76,68,,792.61,Percent of Total Billed Charges,68% of Total Billed Charges,1107.32,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,728.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,728.5,1107.32,
SURGIMESH 10X15,61937,CDM,278,RC,C1781,HCPCS,Outpatient,,,572,400.4,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,388.96,68,,311.17,Percent of Total Billed Charges,68% of Total Billed Charges,434.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,286,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286,434.72,
SURGIMESH 14X15,61938,CDM,278,RC,C1781,HCPCS,Outpatient,,,1001,700.7,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,680.68,68,,544.54,Percent of Total Billed Charges,68% of Total Billed Charges,760.76,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,500.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,14.04,Other,Not Seperately Reimbusable,,,,16.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,12.96,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.41,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.5,760.76,
URINARY INCONTINENCE SLING DEV,61940,CDM,278,RC,Y7509,HCPCS,Outpatient,,,2263,1584.1,,,,,,Other,Not Seperately Reimbusable,1538.84,68,,1231.07,Percent of Total Billed Charges,68% of Total Billed Charges,1719.88,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1131.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1131.5,1719.88,
SNS LEAD - 28CM,61990,CDM,278,RC,Y7509,HCPCS,Outpatient,,,8470,5929,,,,,,Other,Not Seperately Reimbusable,5759.6,68,,4607.68,Percent of Total Billed Charges,68% of Total Billed Charges,6437.2,76,,383.04,Percent of Total Billed Charges,76% of Total Billed Charges,4235,50,,252,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4235,6437.2,
STENT OPEN-TIP URET,62200,CDM,278,RC,C1874,HCPCS,Outpatient,,,142,99.4,,492.41,100,,,fee schedule,100% Aetna Market fee schedule,96.56,68,,77.25,Percent of Total Billed Charges,68% of Total Billed Charges,107.92,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,71,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,11.44,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.32,Other,Not Seperately Reimbusable,,,,58.2,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,10.56,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.59,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.52,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71,107.92,
VAGINAL SLING,62927,CDM,278,RC,C1771,HCPCS,Outpatient,,,2303,1612.1,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,1566.04,68,,1252.83,Percent of Total Billed Charges,68% of Total Billed Charges,1750.28,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1151.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,32.76,Other,Not Seperately Reimbusable,,,,37.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,30.24,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.28,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1151.5,1750.28,
VAGINAL SLING TVT54,62928,CDM,278,RC,C1771,HCPCS,Outpatient,,,3936,2755.2,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,2676.48,68,,2141.18,Percent of Total Billed Charges,68% of Total Billed Charges,2991.36,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,1968,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1968,2991.36,
VENTRALEX MESH SM,63052,CDM,278,RC,C1781,HCPCS,Outpatient,,,1209,846.3,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,822.12,68,,657.7,Percent of Total Billed Charges,68% of Total Billed Charges,918.84,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,604.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,95.76,Other,Not Seperately Reimbusable,,,,102.6,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.5,918.84,
VENTRALEX MESH MED,63053,CDM,278,RC,C1781,HCPCS,Outpatient,,,1448,1013.6,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,984.64,68,,787.71,Percent of Total Billed Charges,68% of Total Billed Charges,1100.48,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,724,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,724,1100.48,
VENTRALEX MESH LG,63054,CDM,278,RC,C1781,HCPCS,Outpatient,,,1613,1129.1,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,1096.84,68,,877.47,Percent of Total Billed Charges,68% of Total Billed Charges,1225.88,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,806.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,10.4,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,296,Other,Not Seperately Reimbusable,,,,320,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.26,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,806.5,1225.88,
ZERO TIP RETRIEVAL BASKET,63110,CDM,278,RC,C1773,HCPCS,Outpatient,,,358,250.6,,70,100,,,fee schedule,100% Aetna Market fee schedule,243.44,68,,194.75,Percent of Total Billed Charges,68% of Total Billed Charges,272.08,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,179,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,226.24,Other,Not Seperately Reimbusable,,,,242.4,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179,272.08,
3D MAX MESH,63197,CDM,278,RC,C1781,HCPCS,Outpatient,,,495,346.5,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,336.6,68,,269.28,Percent of Total Billed Charges,68% of Total Billed Charges,376.2,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,247.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,68.4,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.5,376.2,
PARIETEX MESH,72885,CDM,278,RC,C1781,HCPCS,Outpatient,,,4087,2860.9,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,2779.16,68,,2223.33,Percent of Total Billed Charges,68% of Total Billed Charges,3106.12,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,2043.5,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,711.76,Other,Not Seperately Reimbusable,,,,762.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2043.5,3106.12,
MESH 4CM PCO VENTRAL PARIETEX,73394,CDM,278,RC,,,Outpatient,,,1288,901.6,,,,,,Other,Not Seperately Reimbusable,875.84,68,,700.67,Percent of Total Billed Charges,68% of Total Billed Charges,978.88,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,644,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,837.2,65,,669.76,Percent of Total Billed Charges,65% of Total Billed Charges,966,75,,772.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,340.48,Other,Not Seperately Reimbusable,,,,364.8,Other,Not Seperately Reimbusable,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,772.8,60,,618.24,Percent of Total Billed Charges,60% of Total Billed Charges,262.75,20.4,,210.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.75,20.4,,210.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.6,978.88,
MESH 6CM PCO VENTRAL PARIETEX,73395,CDM,278,RC,,,Outpatient,,,1075,752.5,,,,,,Other,Not Seperately Reimbusable,731,68,,584.8,Percent of Total Billed Charges,68% of Total Billed Charges,817,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,537.5,50,,520,Percent of Total Billed Charges,50% of Total Billed Charges,698.75,65,,559,Percent of Total Billed Charges,65% of Total Billed Charges,806.25,75,,645,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,645,60,,516,Percent of Total Billed Charges,60% of Total Billed Charges,219.3,20.4,,175.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.3,20.4,,175.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215,817,
MESH 8CM PCO VENTRAL PARIETEX,73396,CDM,278,RC,,,Outpatient,,,1654,1157.8,,,,,,Other,Not Seperately Reimbusable,1124.72,68,,899.78,Percent of Total Billed Charges,68% of Total Billed Charges,1257.04,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,827,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,1075.1,65,,860.08,Percent of Total Billed Charges,65% of Total Billed Charges,1240.5,75,,992.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,700.56,Other,Not Seperately Reimbusable,,,,750.6,Other,Not Seperately Reimbusable,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,992.4,60,,793.92,Percent of Total Billed Charges,60% of Total Billed Charges,337.42,20.4,,269.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.42,20.4,,269.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330.8,1257.04,
MESH 8CM PCO VENTRAL PARIETEX,893603,CDM,278,RC,,,Outpatient,,,1654,1157.8,,,,,,Other,Not Seperately Reimbusable,1124.72,68,,899.78,Percent of Total Billed Charges,68% of Total Billed Charges,1257.04,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,827,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1075.1,65,,860.08,Percent of Total Billed Charges,65% of Total Billed Charges,1240.5,75,,992.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,992.4,60,,793.92,Percent of Total Billed Charges,60% of Total Billed Charges,337.42,20.4,,269.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,337.42,20.4,,269.94,Percent of Total Billed Charges,20.4% of Total Billed Charges,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.8,20,,264.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,330.8,1257.04,
MESH 6CM PCO VENTRAL PARIETEX,893604,CDM,278,RC,,,Outpatient,,,1075,752.5,,,,,,Other,Not Seperately Reimbusable,731,68,,584.8,Percent of Total Billed Charges,68% of Total Billed Charges,817,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,537.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,698.75,65,,559,Percent of Total Billed Charges,65% of Total Billed Charges,806.25,75,,645,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,645,60,,516,Percent of Total Billed Charges,60% of Total Billed Charges,219.3,20.4,,175.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,219.3,20.4,,175.44,Percent of Total Billed Charges,20.4% of Total Billed Charges,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215,20,,172,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,215,817,
MESH 4CM PCO VENTRAL PARIETEX,893605,CDM,278,RC,,,Outpatient,,,1288,901.6,,,,,,Other,Not Seperately Reimbusable,875.84,68,,700.67,Percent of Total Billed Charges,68% of Total Billed Charges,978.88,76,,337.82,Percent of Total Billed Charges,76% of Total Billed Charges,644,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,837.2,65,,669.76,Percent of Total Billed Charges,65% of Total Billed Charges,966,75,,772.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,772.8,60,,618.24,Percent of Total Billed Charges,60% of Total Billed Charges,262.75,20.4,,210.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,262.75,20.4,,210.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.6,20,,206.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,257.6,978.88,
CYLINDER-RESERVE-PUMP,28020,CDM,278,RC,C1813,HCPCS,Outpatient,,,24712,17298.4,,7961.62,100,,,fee schedule,100% Aetna Market fee schedule,16804.16,68,,13443.33,Percent of Total Billed Charges,68% of Total Billed Charges,18781.12,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,12356,50,,326.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12356,18781.12,
MALE SLING,60990,CDM,278,RC,C1771,HCPCS,Outpatient,,,11234,7863.8,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,7639.12,68,,6111.3,Percent of Total Billed Charges,68% of Total Billed Charges,8537.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5617,50,,110,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5617,8537.84,
MESH 12X12,61202,CDM,278,RC,C1781,HCPCS,Outpatient,,,2132,1492.4,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,1449.76,68,,1159.81,Percent of Total Billed Charges,68% of Total Billed Charges,1620.32,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,1066,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1066,1620.32,
NEUROELECTRODE IMPLANT,61228,CDM,278,RC,C1778,HCPCS,Outpatient,,,6292,4404.4,,582.6,100,,,fee schedule,100% Aetna Market fee schedule,4278.56,68,,3422.85,Percent of Total Billed Charges,68% of Total Billed Charges,4781.92,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3146,50,,36.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3146,4781.92,
NEUROSTIMULATOR,61230,CDM,278,RC,C1767,HCPCS,Outpatient,,,21175,14822.5,,9908.33,100,,,fee schedule,100% Aetna Market fee schedule,14399,68,,11519.2,Percent of Total Billed Charges,68% of Total Billed Charges,16093,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,10587.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10587.5,16093,
SONY SIS SYSTEM,61945,CDM,278,RC,C1771,HCPCS,Outpatient,,,2303,1612.1,,87.91,100,,,fee schedule,100% Aetna Market fee schedule,1566.04,68,,1252.83,Percent of Total Billed Charges,68% of Total Billed Charges,1750.28,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1151.5,50,,1022.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1151.5,1750.28,
MALLEABLE PENILE PROSTHESIS 9.,72528,CDM,278,RC,C1813,HCPCS,Outpatient,,,16694,11685.8,,7961.62,100,,,fee schedule,100% Aetna Market fee schedule,11351.92,68,,9081.54,Percent of Total Billed Charges,68% of Total Billed Charges,12687.44,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,8347,50,,1022.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8347,12687.44,
TINED LEAD KIT 1201,72584,CDM,278,RC,C1894,HCPCS,Outpatient,,,6702,4691.4,,82.29,100,,,fee schedule,100% Aetna Market fee schedule,4557.36,68,,3645.89,Percent of Total Billed Charges,68% of Total Billed Charges,5093.52,76,,1034.82,Percent of Total Billed Charges,76% of Total Billed Charges,3351,50,,267.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3351,5093.52,
TINED LEAD IMPLANT KIT 1801,72586,CDM,278,RC,C1778,HCPCS,Outpatient,,,690,483,,582.6,100,,,fee schedule,100% Aetna Market fee schedule,469.2,68,,375.36,Percent of Total Billed Charges,68% of Total Billed Charges,524.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,345,50,,326.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,345,524.4,
UROLIFT PROSTHETIC IMPLANT,550533,CDM,278,RC,L8699,HCPCS,Outpatient,,,1606,1124.2,,,,,,Other,Not Seperately Reimbusable,1092.08,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,1220.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,803,50,,28.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,803,1220.56,
ARIS TRANSOBTURATOR KIT,550579,CDM,278,RC,,,Outpatient,,,1918,1342.6,,,,,,Other,Not Seperately Reimbusable,1304.24,68,,1043.39,Percent of Total Billed Charges,68% of Total Billed Charges,1457.68,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,959,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1246.7,65,,997.36,Percent of Total Billed Charges,65% of Total Billed Charges,1438.5,75,,1150.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.6,20,,306.88,Percent of Total Billed Charges,20% of Total Billed Charges,1150.8,60,,920.64,Percent of Total Billed Charges,60% of Total Billed Charges,391.27,20.4,,313.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.27,20.4,,313.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,383.6,20,,306.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.6,20,,306.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.6,1457.68,
SUPRIS RETROPUBIC KIT,550589,CDM,278,RC,C1781,HCPCS,Outpatient,,,1828,1279.6,,452.76,100,,,fee schedule,100% Aetna Market fee schedule,1243.04,68,,994.43,Percent of Total Billed Charges,68% of Total Billed Charges,1389.28,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,914,50,,38.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,914,1389.28,
PNE LEAD IMPLANT KIT,725450,CDM,278,RC,,,Outpatient,,,520,364,,,,,,Other,Not Seperately Reimbusable,353.6,68,,282.88,Percent of Total Billed Charges,68% of Total Billed Charges,395.2,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,260,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,338,65,,270.4,Percent of Total Billed Charges,65% of Total Billed Charges,390,75,,312,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,312,60,,249.6,Percent of Total Billed Charges,60% of Total Billed Charges,106.08,20.4,,84.86,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,106.08,20.4,,84.86,Percent of Total Billed Charges,20.4% of Total Billed Charges,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,20,,83.2,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,104,395.2,
PNE LEAD,725460,CDM,278,RC,,,Outpatient,,,80,56,,,,,,Other,Not Seperately Reimbusable,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,52,65,,41.6,Percent of Total Billed Charges,65% of Total Billed Charges,60,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,48,60,,38.4,Percent of Total Billed Charges,60% of Total Billed Charges,16.32,20.4,,13.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16.32,20.4,,13.06,Percent of Total Billed Charges,20.4% of Total Billed Charges,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,20,,12.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,16,60.8,
CYLINDER SET W PUMP 18 CM,728170,CDM,278,RC,C1813,HCPCS,Outpatient,,,19188,13431.6,,7961.62,100,,,fee schedule,100% Aetna Market fee schedule,13047.84,68,,10438.27,Percent of Total Billed Charges,68% of Total Billed Charges,14582.88,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,9594,50,,192.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9594,14582.88,
CYLINDER SET W PUMP 16CM,729600,CDM,278,RC,C1813,HCPCS,Outpatient,,,19188,13431.6,,7961.62,100,,,fee schedule,100% Aetna Market fee schedule,13047.84,68,,10438.27,Percent of Total Billed Charges,68% of Total Billed Charges,14582.88,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,9594,50,,76.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9594,14582.88,
NON-RECHARGE NEUROSTIM 4101,733000,CDM,278,RC,C1767,HCPCS,Outpatient,,,23302,16311.4,,9908.33,100,,,fee schedule,100% Aetna Market fee schedule,15845.36,68,,12676.29,Percent of Total Billed Charges,68% of Total Billed Charges,17709.52,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,11651,50,,37.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11651,17709.52,
"PALINGEN OR PROMATRX, PER 0.25",893505,CDM,278,RC,Q4174,HCPCS,Outpatient,,,1203,842.1,,1210.14,100,,,fee schedule,100% Aetna Market fee schedule,818.04,68,,654.43,Percent of Total Billed Charges,68% of Total Billed Charges,914.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,601.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.5,914.28,
INSERT TUNNELED CV CATH,5734,CDM,278,RC,C1751,HCPCS,Outpatient,,,550,385,,67.66,100,,,fee schedule,100% Aetna Market fee schedule,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,418,76,,217.66,Percent of Total Billed Charges,76% of Total Billed Charges,275,50,,0.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275,418,
FEEDING TUBES 12 FR,12625,CDM,279,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1568.32,Other,Not Seperately Reimbusable,,,,1809.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,482.56,Other,Not Seperately Reimbusable,,,,1447.68,Other,Not Seperately Reimbusable,,,,492.21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,492.21,Other,Not Seperately Reimbusable,,,,482.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,482.56,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
GLUCERNA 1.2,31822,CDM,279,RC,B4154,HCPCS,Outpatient,,,7,4.9,,0.62,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
GLUCERNA SELECT,31825,CDM,279,RC,B4154,HCPCS,Outpatient,,,6,4.2,,0.62,100,,,fee schedule,100% Aetna Market fee schedule,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
GLUCERNA-BOTTLE,31828,CDM,279,RC,Y7506,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.56,Other,Not Seperately Reimbusable,,,,1.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,1.44,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.49,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.48,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
NUTR/PRO MOD - CAN,31829,CDM,279,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,28.6,Other,Not Seperately Reimbusable,,,,33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,26.4,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.98,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HIPATIC FDG FORMULA,31830,CDM,279,RC,Y7506,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
NEPRO CARB STEADY 1000ML,32935,CDM,279,RC,B4154,HCPCS,Outpatient,1000,ML,7,4.9,,0.62,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
NUTR/ULTRACAL 1060C,32940,CDM,279,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,5.72,Other,Not Seperately Reimbusable,,,,6.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,5.28,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.79,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.76,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
NUTR/DELIVER 2CAL/CC,32945,CDM,279,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
NUTR/DIABETIC RESOURCE,32946,CDM,279,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
NUTR/JEVITY 1.0CAL,32947,CDM,279,RC,,,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,55.94,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,2.6,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,3,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,2.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,0.82,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.82,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.8,3.04,
NUTR/JEVITY 1.5CAL,32948,CDM,279,RC,,,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,48.64,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.08,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,2.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,1.92,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.66,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
NUTR/CHOICE-DM 1060C,32950,CDM,279,RC,Y7506,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,22.04,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,14.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,20.28,Other,Not Seperately Reimbusable,,,,23.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,18.72,Other,Not Seperately Reimbusable,,,,6.37,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.37,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,22.04,
NUTR/NUTREN 1.5,32951,CDM,279,RC,,,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,1.95,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,2.25,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,1.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,0.61,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.61,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,0.6,2.28,
NUTR/OSMOLITE 8OZ,32952,CDM,279,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
NUTREN 2.0 (250ML CAN),32953,CDM,279,RC,,,Outpatient,50,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
NUTR/COMPLY 1500CAL,32955,CDM,279,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
FIBERSOURCE,32959,CDM,279,RC,B4150,HCPCS,Outpatient,,,2,1.4,,0.34,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,3.64,Other,Not Seperately Reimbusable,,,,4.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,3.36,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.14,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
NUTR/TWO CAL HN 1000ML,32960,CDM,279,RC,B4152,HCPCS,Outpatient,1000,ML,4,2.8,,0.28,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,7.28,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,6.72,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.29,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
NUTR/PULMOCARE 1000ML,32965,CDM,279,RC,B4154,HCPCS,Outpatient,1000,ML,3,2.1,,0.62,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,13.52,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,12.48,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.24,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.16,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
FEEDING BAG/TUBE,33470,CDM,279,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,6.76,Other,Not Seperately Reimbusable,,,,7.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,6.24,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.12,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.08,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
SPIKE SET SCREW ON,34135,CDM,279,RC,Y7506,HCPCS,Outpatient,,,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
Y-SITE EXT SET,35025,CDM,279,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,,,,27.04,Other,Not Seperately Reimbusable,,,,31.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,24.96,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.49,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
URETERAL STENT,62924,CDM,279,RC,Y7509,HCPCS,Outpatient,,,467,326.9,,,,,,Other,Not Seperately Reimbusable,317.56,68,,254.05,Percent of Total Billed Charges,68% of Total Billed Charges,354.92,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,233.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,106.08,Other,Not Seperately Reimbusable,,,,122.4,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,47.6,Other,Not Seperately Reimbusable,,,,51,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,97.92,Other,Not Seperately Reimbusable,,,,33.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,33.3,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.5,354.92,
IRRIGATING SYRINGE,69550,CDM,279,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,44.38,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,19.24,Other,Not Seperately Reimbusable,,,,22.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880,Other,Not Seperately Reimbusable,,,,960,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,17.76,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.04,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.92,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
COMPLY NUTRITION 1500CAL,350190,CDM,279,RC,B4152,HCPCS,Outpatient,,,3,2.1,,0.28,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,93.02,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
CHOICE DM NUTRITION 1060CAL,350195,CDM,279,RC,B4154,HCPCS,Outpatient,,,3,2.1,,0.62,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
DELIVER 2.0 NUTRITION,350200,CDM,279,RC,B4152,HCPCS,Outpatient,,,2,1.4,,0.28,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
PROXIMAL SPIKE PUMP SET,350205,CDM,279,RC,B4035,HCPCS,Outpatient,,,11,7.7,,5.24,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,98.46,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
I.V. POLE POUCH PISTION SYRING,350210,CDM,279,RC,B4034,HCPCS,Outpatient,,,10,7,,2.92,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
FEEDING BAG W/ ICE POUCHE,350215,CDM,279,RC,B4036,HCPCS,Outpatient,,,9,6.3,,3.89,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
NEPRO ENTERAL FORMULA,350217,CDM,279,RC,,,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,4.55,65,,3.64,Percent of Total Billed Charges,65% of Total Billed Charges,5.25,75,,4.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,4.2,60,,3.36,Percent of Total Billed Charges,60% of Total Billed Charges,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.43,20.4,,1.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.4,20,,1.12,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.4,5.32,
ULTRACAL NUTRITION 1060CAL,350226,CDM,279,RC,B4150,HCPCS,Outpatient,,,3,2.1,,0.34,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
NEURO LEAD INTRO KIT,60665,CDM,279,RC,C1894,HCPCS,Outpatient,,,618,432.6,,82.29,100,,,fee schedule,100% Aetna Market fee schedule,420.24,68,,336.19,Percent of Total Billed Charges,68% of Total Billed Charges,469.68,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,309,50,,255.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,309,469.68,
NEUROSTIMULATOR TEST KIT,61231,CDM,279,RC,C1897,HCPCS,Outpatient,,,605,423.5,,767.94,100,,,fee schedule,100% Aetna Market fee schedule,411.4,68,,329.12,Percent of Total Billed Charges,68% of Total Billed Charges,459.8,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,302.5,50,,773.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.5,459.8,
CHARGING SYSTEM,61234,CDM,279,RC,C1822,HCPCS,Outpatient,,,1222,855.4,,73.34,100,,,fee schedule,100% Aetna Market fee schedule,830.96,68,,664.77,Percent of Total Billed Charges,68% of Total Billed Charges,928.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,611,50,,2157.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,611,928.72,
PNE LEAD,61236,CDM,279,RC,A4290,HCPCS,Outpatient,,,52,36.4,,57.67,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,39.52,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,26,50,,326.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26,39.52,
EXTERNAL TRIAL STIMULATOR,61237,CDM,279,RC,L8695,HCPCS,Outpatient,,,286,200.2,,7.38,100,,,fee schedule,100% Aetna Market fee schedule,194.48,68,,155.58,Percent of Total Billed Charges,68% of Total Billed Charges,217.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,143,50,,773.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143,217.36,
NEURO PT PROGRAMMERS,61380,CDM,279,RC,C1787,HCPCS,Outpatient,,,2662,1863.4,,59.4,100,,,fee schedule,100% Aetna Market fee schedule,1810.16,68,,1448.13,Percent of Total Billed Charges,68% of Total Billed Charges,2023.12,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1331,50,,242.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1331,2023.12,
PATIENT RMT CNTRL 2301,72547,CDM,279,RC,C1787,HCPCS,Outpatient,,,1686,1180.2,,59.4,100,,,fee schedule,100% Aetna Market fee schedule,1146.48,68,,917.18,Percent of Total Billed Charges,68% of Total Billed Charges,1281.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,843,50,,264.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,843,1281.36,
DRUG SCREEN MULTIPLE,190001,CDM,300,RC,80104,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,37.4,
DRUG SCREEN MULTIPLE,190005,CDM,300,RC,80104,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,381.6,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,37.4,
FECL OCCLT COLRCTL NEOPLSM SCR,201424,CDM,300,RC,82270,HCPCS,Outpatient,,,13,9.1,,2.98,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,66.91,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,8.84,
ADH (ANTI DIURETIC HORMONE),304140,CDM,300,RC,84588,HCPCS,Outpatient,,,65,45.5,,23.08,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,67.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,32.5,67.88,
AFB SMEAR,304145,CDM,300,RC,87206,HCPCS,Outpatient,,,17,11.9,,3.67,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,11.56,
AFB CULTURE,304150,CDM,300,RC,87116,HCPCS,Outpatient,,,32,22.4,,7.34,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,21.76,
ADDITIONAL ID-AEROBIC,304151,CDM,300,RC,87077,HCPCS,Outpatient,,,26,18.2,,5.49,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,17.68,
ADDITIONAL ID-ANAEROBIC,304161,CDM,300,RC,87076,HCPCS,Outpatient,,,26,18.2,,5.49,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,17.68,
ANAEROBIC CULTURE,304171,CDM,300,RC,87075,HCPCS,Outpatient,,,22,15.4,,6.44,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,125.66,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,18.94,
ANTIBIOTIC SENSITIVITY (MIC),304190,CDM,300,RC,87186,HCPCS,Outpatient,,,28,19.6,,5.88,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,19.04,
ANTI H. INFLUENZIAE TYPE B,304191,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
ANTI S. PNEUMONIAE,304192,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
ANTI GRP. B STRETPOCOCCUS,304193,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,140.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
ANTI N. MENNINGITIDIS (C/W135),304194,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
BACTERIAL ANTIGENS,304195,CDM,300,RC,87899,HCPCS,Outpatient,,,38,26.6,,10.93,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,30.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,32.14,
ANTI N. MENNINGITIDIS (A/Y),304196,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
ANTI N. MENNIN. B/E. COLI K1,304197,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
BETA LACTAMASE TEST,304198,CDM,300,RC,87185,HCPCS,Outpatient,,,5,3.5,,3.23,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.4,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,2.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,2.5,9.5,
BLOOD CULTURE,304200,CDM,300,RC,87040,HCPCS,Outpatient,,,33,23.1,,7.02,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,22.44,
BORDETELLA CULTURE,304210,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
C.DIFF COMMON ANTIGEN,304225,CDM,300,RC,87324,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,347.07,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,71.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
CHLAMYDIA CULTURE,304250,CDM,300,RC,87110,HCPCS,Outpatient,,,72,50.4,,13.33,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,39.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,48.96,
COAGALASE TEST,304255,CDM,300,RC,87185,HCPCS,Outpatient,,,5,3.5,,3.23,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.4,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,2.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,9.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,2.5,9.5,
CMV BY PCR,304260,CDM,300,RC,87497,HCPCS,Outpatient,,,136,95.2,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,92.48,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,92.48,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,68,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,92.48,
CRYPTOSPORIDIUM AG,304265,CDM,300,RC,87272,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
CULTURE-STERILE BODY FLUID,304275,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
CULTURE-CSF,304280,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
CYTOMEGALOVIRUS CULT,304290,CDM,300,RC,87252,HCPCS,Outpatient,,,83,58.1,,17.73,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,56.44,
BLOOD PRODUCT POOLING,304300,CDM,300,RC,86965,HCPCS,Outpatient,,,80,56,,21.26,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,47.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,40,208.54,
ENTAMOEBA HIST AG,304323,CDM,300,RC,87337,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
ENTAMOEBA HISTOLYTIC AAB,304324,CDM,300,RC,86753,HCPCS,Outpatient,,,19,13.3,,8.43,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,429.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,9.5,24.78,
FUNGUS CULTURE-BLOOD,304325,CDM,300,RC,87103,HCPCS,Outpatient,,,22,15.4,,13.91,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,11,40.92,
FECAL OCCULT BLOOD IA,304330,CDM,300,RC,82274,HCPCS,Outpatient,,,50,35,QW,10.83,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,34,
FUNGUS CULTURE,304350,CDM,300,RC,87101,HCPCS,Outpatient,,,22,15.4,,5.24,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,15.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,15.42,
EOSINOPHIL OTHER FLUID,304352,CDM,300,RC,87205,HCPCS,Outpatient,,,14,9.8,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,9.52,
EOSINOPHIL CATIONIC PROTEIN,304355,CDM,300,RC,86849,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,108.12,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,79.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,108.12,
FUNGUS CULTURE-OTHER SOURCE,304360,CDM,300,RC,87102,HCPCS,Outpatient,,,27,18.9,,5.72,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,18.36,
FUNGUS/ORGANISM IDENTIFICATION,304375,CDM,300,RC,87106,HCPCS,Outpatient,,,33,23.1,,7.02,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,22.44,
FUNGUS STAIN,304380,CDM,300,RC,87206,HCPCS,Outpatient,,,21,14.7,,3.67,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,577.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,14.28,
KOH PREP-WET MOUNT,304400,CDM,300,RC,87220,HCPCS,Outpatient,,,14,9.8,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,9.52,
GENITAL CULTURE,304410,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
GENERAL VIRAL CULTURE,304415,CDM,300,RC,87252,HCPCS,Outpatient,,,83,58.1,,17.73,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,92.4,Percent of Total Billed Charges,50% of Total Billed Charges,52.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,56.44,
GIARDIA LAMBLIA/EIA,304425,CDM,300,RC,87329,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
GONADOTROPIN RELEASING HORMONE,304427,CDM,300,RC,83727,HCPCS,Outpatient,,,320,224,,11.69,100,,,fee schedule,100% Aetna Market fee schedule,217.6,68,,174.08,Percent of Total Billed Charges,68% of Total Billed Charges,217.6,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,160,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,217.6,
GONNOCOCCUS CULTURE,304450,CDM,300,RC,87081,HCPCS,Outpatient,,,28,19.6,,4.51,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,19.04,
H.PYLORI/STOOL AG,304490,CDM,300,RC,87338,HCPCS,Outpatient,,,24,16.8,,9.78,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,16.32,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,12,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,28.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,12,28.76,
GRAM STAIN,304500,CDM,300,RC,87205,HCPCS,Outpatient,,,14,9.8,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,942.75,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,9.52,
"GROUP B STREP CULTURE, OB SCRE",304501,CDM,300,RC,87081,HCPCS,Outpatient,,,21,14.7,,4.51,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,14.28,
INFLUENZA A/B OIA,304502,CDM,300,RC,87804,HCPCS,Outpatient,,,38,26.6,,11.25,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,33.1,
HERPES VIRAL CULTURE-I/II,304503,CDM,300,RC,87252,HCPCS,Outpatient,,,83,58.1,,17.73,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,52.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,56.44,
H.PYLORI/CLO-TEST,304504,CDM,300,RC,87081,HCPCS,Outpatient,,,21,14.7,,4.51,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,115.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,14.28,
KIRBY BAUER SENSITIV,304505,CDM,300,RC,87184,HCPCS,Outpatient,,,22,15.4,,5.09,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,14.96,
HERPES VIRUS TYPING,304506,CDM,300,RC,87253,HCPCS,Outpatient,,,64,44.8,,13.74,100,,,fee schedule,100% Aetna Market fee schedule,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,43.52,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,32,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,40.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.2,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,43.52,
OXIDASE TEST,304508,CDM,300,RC,87185,HCPCS,Outpatient,,,5,3.5,,3.23,100,,,fee schedule,100% Aetna Market fee schedule,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.4,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,2.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,2.5,9.5,
PNEUMOCYSTIS CARINII-SMEAR,304509,CDM,300,RC,87281,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
H.PYLORI UREA BREATH TEST,304510,CDM,300,RC,83013,HCPCS,Outpatient,,,260,182,,45.8,100,,,fee schedule,100% Aetna Market fee schedule,176.8,68,,141.44,Percent of Total Billed Charges,68% of Total Billed Charges,176.8,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,130,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,134.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,67.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.36,100,,,Fee Schedule,100% of CMS OPPS Rate,67.36,176.8,
H.PYLORI UBT COLLECTION,304515,CDM,300,RC,83014,HCPCS,Outpatient,,,26,18.2,,5.34,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,261.6,Percent of Total Billed Charges,50% of Total Billed Charges,15.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7.86,17.68,
RAPID STREP A,304520,CDM,300,RC,87880,HCPCS,Outpatient,,,38,26.6,,11.24,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,33.06,
RAPID GRP B STREP ANTIGEN,304525,CDM,300,RC,87802,HCPCS,Outpatient,,,38,26.6,,8.66,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,42.98,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,25.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.73,100,,,Fee Schedule,100% of CMS OPPS Rate,12.73,25.84,
INFLUENZA A,304530,CDM,300,RC,87804,HCPCS,Outpatient,,,38,26.6,,11.25,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,33.1,
INFLUENZA B,304535,CDM,300,RC,87804,HCPCS,Outpatient,,,38,26.6,,11.25,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,33.1,
ROUTINE CULTURE,304570,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
STOOL CULTURE,304590,CDM,300,RC,87045,HCPCS,Outpatient,,,30,21,,6.42,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,18.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,20.4,
STOOL SHIGA TOXIN 1,304600,CDM,300,RC,87899,HCPCS,Outpatient,,,38,26.6,,10.93,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,32.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,32.14,
STOOL SHIGA TOXIN 2,304610,CDM,300,RC,87899,HCPCS,Outpatient,,,38,26.6,59,10.93,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,32.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,32.14,
STOOL FOR WBC,304620,CDM,300,RC,89055,HCPCS,Outpatient,,,14,9.8,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,9.52,
SPUTUM CULTURE,304650,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
THROAT CULTURE,304670,CDM,300,RC,87070,HCPCS,Outpatient,,,28,19.6,,5.86,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,19.04,
THROAT CULTURE SINGLE ORGANISM,304675,CDM,300,RC,87081,HCPCS,Outpatient,,,21,14.7,,4.51,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,14.28,
WET PREP,304700,CDM,300,RC,87210,HCPCS,Outpatient,,,14,9.8,,3.96,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,11.64,
URINE CULTURE,304750,CDM,300,RC,87086,HCPCS,Outpatient,,,22,15.4,,5.49,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,16.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,16.14,
HIV-I VIRAL LOAD,304800,CDM,300,RC,87536,HCPCS,Outpatient,,,269,188.3,,57.87,100,,,fee schedule,100% Aetna Market fee schedule,182.92,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,182.92,68,,190.94,Percent of Total Billed Charges,68% of Total Billed Charges,134.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,170.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,182.92,
"AB ID, SELECTED CELLS",308125,CDM,300,RC,86885,HCPCS,Outpatient,,,18,12.6,,3.89,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9,208.54,
ABO TYPE,308150,CDM,300,RC,86900,HCPCS,Outpatient,,,32,22.4,,2.03,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,5.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,155.96,
ANTIBODY IDEN,308300,CDM,300,RC,86870,HCPCS,Outpatient,,,116,81.2,,28.2,100,,,fee schedule,100% Aetna Market fee schedule,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,78.88,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,58,50,,23.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,58,438.87,
ANTIBODY SCREEN,308350,CDM,300,RC,86850,HCPCS,Outpatient,,,148,103.6,,6.64,100,,,fee schedule,100% Aetna Market fee schedule,100.64,68,,80.51,Percent of Total Billed Charges,68% of Total Billed Charges,100.64,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,74,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,19.54,100.64,
ANTIBODY TITER,308360,CDM,300,RC,86886,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,125.66,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,208.54,
ANTIGEN TYPING DONOR UNIT-EA,308375,CDM,300,RC,86902,HCPCS,Outpatient,,,67,46.9,,4.32,100,,,fee schedule,100% Aetna Market fee schedule,45.56,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,45.56,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,33.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.7,438.87,
ANTIGEN TYPING-EACH,308380,CDM,300,RC,86905,HCPCS,Outpatient,,,13,9.1,,2.6,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,56.03,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,438.87,
AUTO CONTROL,308390,CDM,300,RC,86941,HCPCS,Outpatient,,,39,27.3,,8.23,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,26.52,
ARTERIAL BLOOD GAS,308400,CDM,300,RC,82803,HCPCS,Outpatient,,,61,42.7,,17.73,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,52.14,
COOMBS DIRECT,308450,CDM,300,RC,86880,HCPCS,Outpatient,,,17,11.9,,3.67,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,74.68,
COOMBS INDIRECT,308500,CDM,300,RC,86850,HCPCS,Outpatient,,,18,12.6,,6.64,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,9,66.16,
DIFFERENTIAL ADS OF SERUM,308550,CDM,300,RC,86978,HCPCS,Outpatient,,,110,77,,22.83,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,55,74.8,
ENTEROVIRUS DNA BY PCR,308600,CDM,300,RC,87799,HCPCS,Outpatient,,,623,436.1,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,423.64,
DU-VARIANT TESTING,308606,CDM,300,RC,86906,HCPCS,Outpatient,,,25,17.5,,5.27,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,156.67,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.5,48.96,
"ELUTION, EACH",308610,CDM,300,RC,86860,HCPCS,Outpatient,,,110,77,,20.59,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55,208.54,
"ENZYME PRETREAT, EACH",308615,CDM,300,RC,86971,HCPCS,Outpatient,,,33,23.1,,15.22,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,16.5,208.54,
FETAL SCREEN,308620,CDM,300,RC,85461,HCPCS,Outpatient,,,21,14.7,,6.36,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,18.72,
PH,308700,CDM,300,RC,82800,HCPCS,Outpatient,,,27,18.9,,7.48,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,100,,,Fee Schedule,100% of CMS OPPS Rate,11,22,
FRESH FROZEN PL THAW,308720,CDM,300,RC,86927,HCPCS,Outpatient,,,41,28.7,,12.98,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,76,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,20.5,208.53,
PH BODY FLUID,308725,CDM,300,RC,83986,HCPCS,Outpatient,,,17,11.9,,2.43,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,7.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,11.56,
PH-STOOL,308730,CDM,300,RC,83986,HCPCS,Outpatient,,,30,21,,2.43,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,7.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,20.4,
PHLEBOTOMY,308750,CDM,300,RC,99195,HCPCS,Outpatient,,,185,129.5,,91.91,100,,,fee schedule,100% Aetna Market fee schedule,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,125.8,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,92.5,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,164.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,92.5,164.58,
KLEIHAUER BETKE STAIN,308760,CDM,300,RC,85460,HCPCS,Outpatient,,,116,81.2,,5.26,100,,,fee schedule,100% Aetna Market fee schedule,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,78.88,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,58,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,78.88,
RH PHENOTYPE,308925,CDM,300,RC,86906,HCPCS,Outpatient,,,25,17.5,,5.27,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,15.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.5,48.96,
RH TYPE,308950,CDM,300,RC,86901,HCPCS,Outpatient,,,32,22.4,,2.03,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,48.96,
ANTIGLOBULIN TECHNIQUE,308973,CDM,300,RC,86850,HCPCS,Outpatient,,,112,78.4,,6.64,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,19.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,19.54,76.16,
COMP TEST-IMMEDIATE SPIN,308990,CDM,300,RC,86920,HCPCS,Outpatient,,,104,72.8,,22.83,100,,,fee schedule,100% Aetna Market fee schedule,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,70.72,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,52,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,52,208.54,
SEP BY DENSITY GRADIENT,308995,CDM,300,RC,86971,HCPCS,Outpatient,,,132,92.4,,15.22,100,,,fee schedule,100% Aetna Market fee schedule,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,89.76,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,66,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,66,208.54,
ACETYLCHOLINE RECEPT,310420,CDM,300,RC,84238,HCPCS,Outpatient,,,116,81.2,,24.87,100,,,fee schedule,100% Aetna Market fee schedule,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,78.88,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,58,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,73.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,78.88,
ACID PHOSPHATASE,310450,CDM,300,RC,84060,HCPCS,Outpatient,,,24,16.8,,5.2,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,16.32,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,12,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.64,100,,,Fee Schedule,100% of CMS OPPS Rate,7.64,16.32,
ACTH-PLASMA-1 SPEC,310470,CDM,300,RC,82024,HCPCS,Outpatient,,,123,86.1,,26.26,100,,,fee schedule,100% Aetna Market fee schedule,83.64,68,,66.91,Percent of Total Billed Charges,68% of Total Billed Charges,83.64,68,,187.68,Percent of Total Billed Charges,68% of Total Billed Charges,61.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,77.23,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.62,100,,,Fee Schedule,100% of CMS OPPS Rate,38.62,83.64,
"ACYLCARNITINE, QUANTITATIVE PL",310480,CDM,300,RC,82017,HCPCS,Outpatient,,,252,176.4,,11.47,100,,,fee schedule,100% Aetna Market fee schedule,171.36,68,,137.09,Percent of Total Billed Charges,68% of Total Billed Charges,171.36,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,126,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,171.36,
ALBUMIN (SERUM),310500,CDM,300,RC,82040,HCPCS,Outpatient,,,16,11.2,,3.37,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,10.88,
ALBUMIN TIMED URINE,310510,CDM,300,RC,82042,HCPCS,Outpatient,,,17,11.9,,5.29,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,200.74,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,15.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,15.56,
ALBUMIN-BODY FLUID,310520,CDM,300,RC,82042,HCPCS,Outpatient,,,17,11.9,,5.29,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,15.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,15.56,
SERUM ETHANOL,310550,CDM,300,RC,80320,HCPCS,Outpatient,,,35,24.5,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,23.8,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,23.8,
ALDOLASE,310555,CDM,300,RC,82085,HCPCS,Outpatient,,,31,21.7,,6.6,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,21.08,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.5,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,21.08,
ALDOSTERONE,310560,CDM,300,RC,82088,HCPCS,Outpatient,,,129,90.3,,27.71,100,,,fee schedule,100% Aetna Market fee schedule,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,87.72,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,64.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,81.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,87.72,
SERUM 5-HIAA,310590,CDM,300,RC,84260,HCPCS,Outpatient,,,63,44.1,,21.07,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,42.84,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,31.5,50,,168.8,Percent of Total Billed Charges,50% of Total Billed Charges,61.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,61.96,
SHBG (SEX HORMONE BINDING GLOB,310595,CDM,300,RC,84270,HCPCS,Outpatient,,,39,27.3,,14.78,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,48.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,43.46,
ALKALINE PHOS.,310600,CDM,300,RC,84075,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,269.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
ALK PHOS ISOENZYMES,310625,CDM,300,RC,84080,HCPCS,Outpatient,,,47,32.9,,10.05,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,88.67,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,31.96,
PROSTATIC ACID PHOS,310650,CDM,300,RC,84066,HCPCS,Outpatient,,,31,21.7,,6.57,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,21.08,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,15.5,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.66,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.66,21.08,
"ALLERGENS, ZONE 10",310660,CDM,300,RC,82785,HCPCS,Outpatient,,,146,102.2,,11.19,100,,,fee schedule,100% Aetna Market fee schedule,99.28,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,99.28,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,73,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,32.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,99.28,
ALPHA SUBUNIT (FREE),310675,CDM,300,RC,82397,HCPCS,Outpatient,,,90,63,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,61.2,
ALPHA-1-ANTITRYPSIN (TOTAL),310680,CDM,300,RC,82103,HCPCS,Outpatient,,,48,33.6,,9.14,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,338,Percent of Total Billed Charges,50% of Total Billed Charges,26.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,32.64,
ALPRAZOLAM (XANAX),310685,CDM,300,RC,80346,HCPCS,Outpatient,,,59,41.3,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,23.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,40.12,
AFP TRIPLE SCREEN,310690,CDM,300,RC,81510,HCPCS,Outpatient,,,151,105.7,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,102.68,68,,82.14,Percent of Total Billed Charges,68% of Total Billed Charges,102.68,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,75.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,111.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.54,100,,,Fee Schedule,100% of CMS OPPS Rate,55.54,111.08,
AFP QUAD SCREEN,310695,CDM,300,RC,81511,HCPCS,Outpatient,,,201,140.7,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,136.68,68,,109.34,Percent of Total Billed Charges,68% of Total Billed Charges,136.68,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,100.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,307,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,153.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,100.5,307,
AFP  (MATERNAL SERUM),310700,CDM,300,RC,82105,HCPCS,Outpatient,,,53,37.1,,11.4,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,33.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,36.04,
AMBIEN (ZOLPIDEM) LEVEL,310702,CDM,300,RC,82491,HCPCS,Outpatient,,,264,184.8,,,,,,Other,Not Seperately Reimbusable,179.52,68,,143.62,Percent of Total Billed Charges,68% of Total Billed Charges,179.52,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,132,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132,179.52,
ESTRIOL (FREE),310703,CDM,300,RC,82677,HCPCS,Outpatient,,,76,53.2,,16.44,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,48.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,51.68,
AMIODARONE,310704,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
AFP-TUMOR MARKER,310705,CDM,300,RC,82105,HCPCS,Outpatient,,,53,37.1,,11.4,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,36.04,
AMIKACIN LEVEL,310706,CDM,300,RC,80150,HCPCS,Outpatient,,,58,40.6,,10.25,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,37.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,39.44,
AMH (ANTI MULLERIAN HORMONE),310708,CDM,300,RC,83520,HCPCS,Outpatient,,,100,70,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,68,68,,54.4,Percent of Total Billed Charges,68% of Total Billed Charges,68,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,50,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,68,
AMITRIPTYLINE,310710,CDM,300,RC,80152,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,287.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,38.76,
NORTRIPTYLINE,310720,CDM,300,RC,80182,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,38,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
ALLERGEN PROFILE-FOOD,310725,CDM,300,RC,86003,HCPCS,Outpatient,,,62,43.4,,3.55,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,42.16,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,31,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,42.16,
ALLERGEN PANEL MILK,310727,CDM,300,RC,86003,HCPCS,Outpatient,,,106,74.2,,3.55,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,72.08,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,53,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,72.08,
ALLERGEN PROFILE-NON FOOD,310730,CDM,300,RC,86003,HCPCS,Outpatient,,,662,463.4,,3.55,100,,,fee schedule,100% Aetna Market fee schedule,450.16,68,,360.13,Percent of Total Billed Charges,68% of Total Billed Charges,450.16,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,331,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,450.16,
AMPHETAMINES,310732,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
AMPHETAMINE CONFIRMATION,310734,CDM,300,RC,80324,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
AMYLASE,310750,CDM,300,RC,82150,HCPCS,Outpatient,,,21,14.7,,4.41,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,14.28,
AMYLASE-ISOENZYMES,310760,CDM,300,RC,82664,HCPCS,Outpatient,,,108,75.6,,41.82,100,,,fee schedule,100% Aetna Market fee schedule,73.44,68,,58.75,Percent of Total Billed Charges,68% of Total Billed Charges,73.44,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,54,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,123,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,54,123,
ANDROSTENEDIONE,310790,CDM,300,RC,82157,HCPCS,Outpatient,,,93,65.1,,19.91,100,,,fee schedule,100% Aetna Market fee schedule,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,63.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,46.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,58.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,63.24,
ANDROGEN FREE INDEX SHBG,310792,CDM,300,RC,84270,HCPCS,Outpatient,,,76,53.2,,14.78,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,51.68,
ANDROGEN FREE INDEX TT,310794,CDM,300,RC,84403,HCPCS,Outpatient,,,96,67.2,,17.55,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,65.28,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,48,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,51.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,65.28,
ARSENIC-URINE,310795,CDM,300,RC,82175,HCPCS,Outpatient,,,60,42,,12.9,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,40.8,
BERYLLIUM-SERUM,310800,CDM,300,RC,83018,HCPCS,Outpatient,,,70,49,,14.93,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,43.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,47.6,
BERYLIUM,310805,CDM,300,RC,83018,HCPCS,Outpatient,,,336,235.2,,14.93,100,,,fee schedule,100% Aetna Market fee schedule,228.48,68,,182.78,Percent of Total Billed Charges,68% of Total Billed Charges,228.48,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,168,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,43.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,228.48,
ANGIOTENSIN CNVRT ENZ (ACE),310810,CDM,300,RC,82164,HCPCS,Outpatient,,,47,32.9,,9.93,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,103.36,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,396,Percent of Total Billed Charges,50% of Total Billed Charges,29.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,31.96,
ANTI BORDETELLA PERTUSIS,310820,CDM,300,RC,86615,HCPCS,Outpatient,,,42,29.4,,8.97,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,28.56,
ANTI B. MICROTI AB IGG/IGM,310822,CDM,300,RC,86753,HCPCS,Outpatient,,,53,37.1,,8.43,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,36.04,
ANTI ENDOMYSIAL AB,310823,CDM,300,RC,86256,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTI CENTROMERE AB,310825,CDM,300,RC,86256,HCPCS,Outpatient,,,53,37.1,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,36.04,
ANTI CENTROMERE B ANTIBODY,310827,CDM,300,RC,86235,HCPCS,Outpatient,,,20,14,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,10,35.86,
ANTI DNASE B,310829,CDM,300,RC,86215,HCPCS,Outpatient,,,42,29.4,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,176.8,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,254.8,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,28.56,
ANTI DS-DNA ANTIBODY,310830,CDM,300,RC,86225,HCPCS,Outpatient,,,43,30.1,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,29.24,
ANTI JO1,310831,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI ENA-RNP,310832,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI HISTONE,310834,CDM,300,RC,86256,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTICARDIOLIPIN AB (EACH IGG C,310835,CDM,300,RC,86147,HCPCS,Outpatient,,,81,56.7,,17.31,100,,,fee schedule,100% Aetna Market fee schedule,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,55.08,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,40.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,55.08,
ANTI HISTONE AB,310836,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI SS-DNA ANTIBODY,310837,CDM,300,RC,86226,HCPCS,Outpatient,,,39,27.3,,8.23,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,26.52,
ANTI RNP AB,310838,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI SRP  (SIGNAL RECOGNITION,310839,CDM,300,RC,86235,HCPCS,Outpatient,,,179,125.3,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,121.72,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,89.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,121.72,
ANTI PLATELET ANTIB,310840,CDM,300,RC,86023,HCPCS,Outpatient,,,40,28,,8.47,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,27.2,
ANTI PM1,310841,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,37.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI GAD65,310842,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,396,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
ANTI SCLERODERMA AB (SCL70),310845,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
ANTI INTRINSIC FACTOR AB,310846,CDM,300,RC,86340,HCPCS,Outpatient,,,66,46.2,,10.25,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,30.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,44.88,
ANTI ISLET CELL,310847,CDM,300,RC,86341,HCPCS,Outpatient,,,37,25.9,,16.03,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,89.6,Percent of Total Billed Charges,50% of Total Billed Charges,47.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,47.14,
ANTI M 2,310849,CDM,300,RC,83516,HCPCS,Outpatient,,,52,36.4,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,35.36,
ANTI MITOCHONDIAL ANT,310850,CDM,300,RC,86256,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTI MYELOPEROXIDASE,310851,CDM,300,RC,86021,HCPCS,Outpatient,,,62,43.4,,10.23,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,42.16,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,31,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,42.16,
ANTI STRIATED MUSCLE AB,310853,CDM,300,RC,86255,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTI SULFATIDE AB,310854,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,229.57,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
ANTI PARIETAL ANTIBODY,310855,CDM,300,RC,86256,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTI PHOSPHOLIPID,310858,CDM,300,RC,86148,HCPCS,Outpatient,,,51,35.7,,10.93,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,366.11,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,34.68,
ANTI PROTEINASE 3 (PR3),310859,CDM,300,RC,86021,HCPCS,Outpatient,,,62,43.4,,10.23,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,42.16,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,30.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,42.16,
ANTI SMOOTH MUSC ANT,310860,CDM,300,RC,86255,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
ANTI-THROMBIN III,310861,CDM,300,RC,85300,HCPCS,Outpatient,,,159,111.3,,8.06,100,,,fee schedule,100% Aetna Market fee schedule,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,108.12,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,79.5,50,,231.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,108.12,
ANTITHYROID ANTIBODY,310865,CDM,300,RC,86376,HCPCS,Outpatient,,,58,40.6,,9.89,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,39.44,
ARTERIAL COLLECTION,310870,CDM,300,RC,36600,HCPCS,Outpatient,,,58,40.6,,15.86,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,459.68,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.3,155.96,
ASCA (SACCHAROMYCES CEREVISIAE,310879,CDM,300,RC,86671,HCPCS,Outpatient,,,251,175.7,,8.33,100,,,fee schedule,100% Aetna Market fee schedule,170.68,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,170.68,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,125.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,170.68,
ASPERGILLUS-AB,310880,CDM,300,RC,86606,HCPCS,Outpatient,,,48,33.6,,10.23,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,32.64,
B-NATRUIRETIC PEPTIDE-PLASMA,310885,CDM,300,RC,83880,HCPCS,Outpatient,,,88,61.6,,26.7,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,59.84,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,44,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,78.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,39.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,78.52,
URINE BENCE-JONES PROTEIN,310890,CDM,300,RC,86335,HCPCS,Outpatient,,,50,35,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,58.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25,58.7,
BARTONELLA IGG ANTIBODY,310891,CDM,300,RC,86611,HCPCS,Outpatient,,,303,212.1,,6.92,100,,,fee schedule,100% Aetna Market fee schedule,206.04,68,,164.83,Percent of Total Billed Charges,68% of Total Billed Charges,206.04,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,151.5,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,20.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,206.04,
BETA-2 MICROGLOBULIN,310895,CDM,300,RC,82232,HCPCS,Outpatient,,,58,40.6,,11,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,137.09,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,201.2,Percent of Total Billed Charges,50% of Total Billed Charges,32.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,39.44,
"BETA-2 GLYCOPROTEIN I AB,G,A,M",310896,CDM,300,RC,86146,HCPCS,Outpatient,,,50,35,,17.31,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25,50.9,
BLASTOMYCES-AB,310900,CDM,300,RC,86612,HCPCS,Outpatient,,,41,28.7,,8.77,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,27.88,
BCRC-ABL1 (PCR),310925,CDM,300,RC,81403,HCPCS,Outpatient,,,787,550.9,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,535.16,68,,428.13,Percent of Total Billed Charges,68% of Total Billed Charges,535.16,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,393.5,50,,308,Percent of Total Billed Charges,50% of Total Billed Charges,370.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,185.2,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,535.16,
BARBITURATES,310930,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,229.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
BARBITURATE CONFIRMATION,310932,CDM,300,RC,80345,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,390.59,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
BAS. METABOLIC PANEL,310938,CDM,300,RC,80048,HCPCS,Outpatient,,,27,18.9,,5.75,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,65.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,18.36,
BENZODIAZEPINES,310946,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
BENZODIAZEPINE CONFIRMATION,310948,CDM,300,RC,80346,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,159.39,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,18.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
BILIRUBIN DIR.,310950,CDM,300,RC,82248,HCPCS,Outpatient,,,16,11.2,,3.41,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.03,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,10.88,
PANCA-ANTIMYELOPEROXIDASE ANTI,310975,CDM,300,RC,86021,HCPCS,Outpatient,,,70,49,,10.23,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,47.6,
BILIRUBIN TOTAL,311000,CDM,300,RC,82247,HCPCS,Outpatient,,,16,11.2,,3.41,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.03,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,10.88,
AMINO ACID-PLASMA EA,311040,CDM,300,RC,82131,HCPCS,Outpatient,,,53,37.1,,15.63,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,45.96,
AMINO ACID SERUM QUANTITATIVE,311045,CDM,300,RC,82139,HCPCS,Outpatient,,,202,141.4,,11.47,100,,,fee schedule,100% Aetna Market fee schedule,137.36,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,137.36,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,101,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,137.36,
AMMONIA (SERUM),311050,CDM,300,RC,82140,HCPCS,Outpatient,,,47,32.9,,9.91,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,31.96,
AMMONIA-URINE,311060,CDM,300,RC,82140,HCPCS,Outpatient,,,47,32.9,,9.91,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,31.96,
LEAD LEVEL (SERUM),311100,CDM,300,RC,83655,HCPCS,Outpatient,,,39,27.3,,8.23,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,26.52,
LACTOFERRIN,311120,CDM,300,RC,83631,HCPCS,Outpatient,,,173,121.1,,13.35,100,,,fee schedule,100% Aetna Market fee schedule,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,117.64,68,,75.62,Percent of Total Billed Charges,68% of Total Billed Charges,86.5,50,,37.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,117.64,
LEPTIN SERUM,311125,CDM,300,RC,83520,HCPCS,Outpatient,,,67,46.9,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,45.56,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,45.56,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,33.5,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,45.56,
BLOOD UREA NITROGEN (BUN),311150,CDM,300,RC,84520,HCPCS,Outpatient,,,13,9.1,,2.69,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,52.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,8.84,
C1Q QUANTITATIVE,311152,CDM,300,RC,86160,HCPCS,Outpatient,,,24,16.8,,8.16,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,16.32,68,,538.56,Percent of Total Billed Charges,68% of Total Billed Charges,12,50,,204.4,Percent of Total Billed Charges,50% of Total Billed Charges,24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,24,
BTA-BLADDER TUMOR AN,311155,CDM,300,RC,86294,HCPCS,Outpatient,,,37,25.9,,17.39,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,312.8,Percent of Total Billed Charges,50% of Total Billed Charges,51.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,51.14,
C2 COMPLEMENT,311157,CDM,300,RC,86160,HCPCS,Outpatient,,,38,26.6,,8.16,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,25.84,
BLOOD CULTURE AEL,311158,CDM,300,RC,87040,HCPCS,Outpatient,,,44,30.8,,7.02,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,29.92,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,22,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,29.92,
C-1 ESTERASE INHIBITOR,311160,CDM,300,RC,86161,HCPCS,Outpatient,,,38,26.6,,8.16,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,25.84,
C-TERMINAL TELOPEPTIDE,311165,CDM,300,RC,82397,HCPCS,Outpatient,,,60,42,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,40.8,
CALCIUM (URINE),311170,CDM,300,RC,82340,HCPCS,Outpatient,,,19,13.3,,4.1,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,346.53,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,12.92,
BMP WITH IONIZED CALCIUM,311175,CDM,300,RC,80047,HCPCS,Outpatient,,,27,18.9,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,81.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,27.46,
CACOSAMIDE LEVEL,311180,CDM,300,RC,80339,HCPCS,Outpatient,,,678,474.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,461.04,68,,368.83,Percent of Total Billed Charges,68% of Total Billed Charges,461.04,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,339,50,,76.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339,461.04,
CALCITONIA-SERUM,311190,CDM,300,RC,82308,HCPCS,Outpatient,,,85,59.5,,18.22,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,53.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.79,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,57.8,
CALCIUM (SERUM),311200,CDM,300,RC,82310,HCPCS,Outpatient,,,17,11.9,,3.51,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.16,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,11.56,
CALCIUM-24HR URINE,311210,CDM,300,RC,82340,HCPCS,Outpatient,,,19,13.3,,4.1,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,12.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,12.92,
CHROMOSOME ANALYSIS - BLOOD,311211,CDM,300,RC,88262,HCPCS,Outpatient,,,436,305.2,,85.33,100,,,fee schedule,100% Aetna Market fee schedule,296.48,68,,237.18,Percent of Total Billed Charges,68% of Total Billed Charges,296.48,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,218,50,,48.4,Percent of Total Billed Charges,50% of Total Billed Charges,250.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,125.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,296.48,
CYTOGENETICS,311213,CDM,300,RC,88291,HCPCS,Outpatient,,,64,44.8,,22.22,100,,,fee schedule,100% Aetna Market fee schedule,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,43.52,68,,76.16,Percent of Total Billed Charges,68% of Total Billed Charges,32,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,62.22,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32,62.22,
CALCULI-URINE,311220,CDM,300,RC,82360,HCPCS,Outpatient,,,85,59.5,,8.75,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,57.8,
CELIAC HLA REFLEX TO ABS,311221,CDM,300,RC,81377,HCPCS,Outpatient,,,638,446.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,433.84,68,,347.07,Percent of Total Billed Charges,68% of Total Billed Charges,433.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,319,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,189.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.74,100,,,Fee Schedule,100% of CMS OPPS Rate,94.74,433.84,
CELIAC DISEASE COMP,311222,CDM,300,RC,82784,HCPCS,Outpatient,,,130,91,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,88.4,
"CELIAC DISEASE COMP IA, MULTI",311223,CDM,300,RC,83516,HCPCS,Outpatient,,,130,91,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,538.56,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,88.4,
CAPILLARY COLLECTION,311224,CDM,300,RC,36416,HCPCS,Outpatient,,,16,11.2,,2.01,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,10.88,
CANCA-ANTIPROTEINASE 3/PR3 ANT,311225,CDM,300,RC,83520,HCPCS,Outpatient,,,70,49,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,47.6,
CELIAC HLA II TYPING,311226,CDM,300,RC,81383,HCPCS,Outpatient,,,589,412.3,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,400.52,68,,320.42,Percent of Total Billed Charges,68% of Total Billed Charges,400.52,68,,121.86,Percent of Total Billed Charges,68% of Total Billed Charges,294.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,218.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,109.13,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,400.52,
"CELIAC DISEASE COMP FNIA AB, S",311227,CDM,300,RC,86255,HCPCS,Outpatient,,,130,91,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,88.4,
CHRONIC URTICARIA INDEX PANEL,311235,CDM,300,RC,86352,HCPCS,Outpatient,,,110,77,,92.38,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,271.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,55,271.72,
CARBAMAZEPINE,311250,CDM,300,RC,80156,HCPCS,Outpatient,,,47,32.9,,9.91,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,31.96,
CYCLIC CITRULLINATED PEPTIDE A,311255,CDM,300,RC,86200,HCPCS,Outpatient,,,41,28.7,,8.81,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,25.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,27.88,
CARBOHYDRATE ANT19-9,311258,CDM,300,RC,86301,HCPCS,Outpatient,,,66,46.2,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,44.88,
CARBOXYHEMOGLOBIN,311260,CDM,300,RC,82375,HCPCS,Outpatient,,,39,27.3,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,26.52,
CELEXA (CITALOPRAM),311264,CDM,300,RC,82491,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
CLONIDINE SERUM,311265,CDM,300,RC,80299,HCPCS,Outpatient,,,59,41.3,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,40.12,
CYCLOSPORIN LEVEL,311275,CDM,300,RC,80158,HCPCS,Outpatient,,,58,40.6,,12.27,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,39.44,
CLOZAPINE LEVEL,311280,CDM,300,RC,80299,HCPCS,Outpatient,,,150,105,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,102,68,,314.43,Percent of Total Billed Charges,68% of Total Billed Charges,75,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,102,
CARCINOGENIC EMB.ANT,311300,CDM,300,RC,82378,HCPCS,Outpatient,,,60,42,,12.89,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,40.8,
CA125 - OVARIAN CA,311310,CDM,300,RC,86304,HCPCS,Outpatient,,,66,46.2,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,324.4,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,44.88,
CA27-29,311320,CDM,300,RC,86300,HCPCS,Outpatient,,,652,456.4,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,443.36,68,,354.69,Percent of Total Billed Charges,68% of Total Billed Charges,443.36,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,326,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,443.36,
CA15-3 BREAST CANCER,311325,CDM,300,RC,86300,HCPCS,Outpatient,,,66,46.2,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,44.88,
CATECHOLAMINES-TOTAL-BLOOD,311350,CDM,300,RC,82383,HCPCS,Outpatient,,,80,56,,19.77,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,58.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,58.16,
ABSOLUTE CD4/CD8 W/RATIO,311385,CDM,300,RC,86360,HCPCS,Outpatient,,,59,41.3,,31.95,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,124.03,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,93.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,46.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.5,93.96,
CHLAMYDIA ANTIBODY IGM,311395,CDM,300,RC,86632,HCPCS,Outpatient,,,40,28,,8.62,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,189.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,27.2,
CHRONIC URTICARIA,311397,CDM,300,RC,86352,HCPCS,Outpatient,,,105,73.5,,92.38,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,71.4,68,,273.63,Percent of Total Billed Charges,68% of Total Billed Charges,52.5,50,,216.8,Percent of Total Billed Charges,50% of Total Billed Charges,271.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,52.5,271.72,
CSF GLUCOSE,311400,CDM,300,RC,82945,HCPCS,Outpatient,,,13,9.1,,2.67,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,8.84,
CERULOPLASMIN,311401,CDM,300,RC,82390,HCPCS,Outpatient,,,35,24.5,,7.3,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,23.8,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,21.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,23.8,
CMV ANTIBODY IGG,311405,CDM,300,RC,86644,HCPCS,Outpatient,,,58,40.6,,9.79,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,418.88,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,39.44,
CMV AB IGM,311425,CDM,300,RC,86645,HCPCS,Outpatient,,,58,40.6,,11.46,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,312.26,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,51.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,39.44,
CEREBROSPINAL FD.PRO,311450,CDM,300,RC,84157,HCPCS,Outpatient,,,13,9.1,,2.72,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,8.84,
COCCIDIODES-AB,311475,CDM,300,RC,86635,HCPCS,Outpatient,,,37,25.9,,7.8,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,89.22,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,22.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,25.16,
CCP AB,311480,CDM,300,RC,86200,HCPCS,Outpatient,,,53,37.1,,8.81,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,36.04,
CD19 CELL SURF. MARK,311490,CDM,300,RC,88180,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,60.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,57.8,
CHLORIDE-SERUM,311500,CDM,300,RC,82435,HCPCS,Outpatient,,,15,10.5,,3.13,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,89.2,Percent of Total Billed Charges,50% of Total Billed Charges,9.19,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.6,10.2,
CHLORIDE-SPINAL FLD,311510,CDM,300,RC,82438,HCPCS,Outpatient,,,16,11.2,,3.4,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,10,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,10.88,
CHLORIDE-URINE,311520,CDM,300,RC,82436,HCPCS,Outpatient,,,16,11.2,,3.91,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,11.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,11.5,
CHOLESTEROL (TOTAL),311550,CDM,300,RC,82465,HCPCS,Outpatient,,,14,9.8,,2.96,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,8.69,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4.35,9.52,
CHOLINESTERASE SERUM,311555,CDM,300,RC,82480,HCPCS,Outpatient,,,39,27.3,,5.35,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,15.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,26.52,
CHROMOGRANIN A,311560,CDM,300,RC,86316,HCPCS,Outpatient,,,95,66.5,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,47.5,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,64.6,
C.TRACOMATIS AB IGG,311570,CDM,300,RC,86631,HCPCS,Outpatient,,,38,26.6,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,113.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,25.84,
C.TRACOMATIS AB IGM,311575,CDM,300,RC,86632,HCPCS,Outpatient,,,40,28,,8.62,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,216.8,Percent of Total Billed Charges,50% of Total Billed Charges,25.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,27.2,
C.DIFF TOXIN,311580,CDM,300,RC,87493,HCPCS,Outpatient,,,83,58.1,,25.34,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,74.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,74.54,
COCAINE,311590,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
COCAINE CONFIRMATION,311592,CDM,300,RC,80353,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
COBALT,311595,CDM,300,RC,83018,HCPCS,Outpatient,,,259,181.3,,14.93,100,,,fee schedule,100% Aetna Market fee schedule,176.12,68,,140.9,Percent of Total Billed Charges,68% of Total Billed Charges,176.12,68,,277.98,Percent of Total Billed Charges,68% of Total Billed Charges,129.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,43.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,176.12,
CO2 CONTENT-TOTAL,311600,CDM,300,RC,82374,HCPCS,Outpatient,,,10,7,,3.32,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,425.41,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,9.76,
COPPER (SERUM),311605,CDM,300,RC,82525,HCPCS,Outpatient,,,40,28,,8.44,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,27.2,
COMPLEMENT C-3,311610,CDM,300,RC,86160,HCPCS,Outpatient,,,38,26.6,,8.16,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,25.84,
COMPLEMENT C-4,311615,CDM,300,RC,86160,HCPCS,Outpatient,,,38,26.6,,8.16,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,25.84,
COMPLEMENT-TOTAL (CH50),311617,CDM,300,RC,86162,HCPCS,Outpatient,,,64,44.8,,13.82,100,,,fee schedule,100% Aetna Market fee schedule,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,43.52,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,43.52,
COM. METABOLIC PANEL,311620,CDM,300,RC,80053,HCPCS,Outpatient,,,33,23.1,,7.18,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,22.44,
COPPER-URINE 24HR,311625,CDM,300,RC,82525,HCPCS,Outpatient,,,40,28,,8.44,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,110.98,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,24.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,27.2,
CORTICOSTERONE SERUM,311635,CDM,300,RC,82528,HCPCS,Outpatient,,,117,81.9,,15.31,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,79.56,68,,103.9,Percent of Total Billed Charges,68% of Total Billed Charges,58.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.52,100,,,Fee Schedule,100% of CMS OPPS Rate,22.52,79.56,
CORTICOSTERIOD BIND GLOB (CBG),311640,CDM,300,RC,84449,HCPCS,Outpatient,,,60,42,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,40.8,
CORTISOL (TOTAL),311650,CDM,300,RC,82533,HCPCS,Outpatient,,,52,36.4,,11.08,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,35.36,
CORTISOL (FREE),311655,CDM,300,RC,82530,HCPCS,Outpatient,,,53,37.1,,11.36,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,36.04,
BRCA #1,311660,CDM,300,RC,81215,HCPCS,Outpatient,,,1606,1124.2,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,1092.08,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,1092.08,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,803,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,750.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS Rate,375.25,1092.08,
BRCA #2,311665,CDM,300,RC,81217,HCPCS,Outpatient,,,1606,1124.2,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,1092.08,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,1092.08,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,803,50,,59.6,Percent of Total Billed Charges,50% of Total Billed Charges,750.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.25,100,,,Fee Schedule,100% of CMS OPPS Rate,375.25,1092.08,
C-PEPTID,311680,CDM,300,RC,84681,HCPCS,Outpatient,,,66,46.2,,14.15,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,44.88,
CREAT. CLEAR,311700,CDM,300,RC,82575,HCPCS,Outpatient,,,30,21,,6.43,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,107.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,20.4,
CRYPTOCOCCAL ANTIBODY,311705,CDM,300,RC,86641,HCPCS,Outpatient,,,46,32.2,,9.8,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,28.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,31.28,
CRYPTOCOCCAL ANTIGEN (EIA),311710,CDM,300,RC,86403,HCPCS,Outpatient,,,48,33.6,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,32.64,
CREATINE KINASE (CK),311750,CDM,300,RC,82550,HCPCS,Outpatient,,,21,14.7,,4.43,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,54.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,14.28,
CK-MB,311800,CDM,300,RC,82553,HCPCS,Outpatient,,,37,25.9,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,25.16,
CYANIDE,311840,CDM,300,RC,82600,HCPCS,Outpatient,,,41,28.7,,13.19,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,100,,,Fee Schedule,100% of CMS OPPS Rate,19.4,38.79,
CREATININE-URINE (RANDOM),311845,CDM,300,RC,82570,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
CREATININE-SERUM,311850,CDM,300,RC,82565,HCPCS,Outpatient,,,17,11.9,,3.48,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,11.56,
CREATININE-URINE 24H,311855,CDM,300,RC,82570,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
CYSTATIN C,311857,CDM,300,RC,82610,HCPCS,Outpatient,,,43,30.1,,12.59,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,37.04,
CRYOGLOBULINS (QUALITATIVE),311862,CDM,300,RC,82595,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
CYCLOSPORIN LEVEL,311865,CDM,300,RC,80158,HCPCS,Outpatient,,,58,40.6,,12.27,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,54.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,39.44,
CRYSTAL EX-SYNOV.FLD,311870,CDM,300,RC,89060,HCPCS,Outpatient,,,22,15.4,,4.98,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,14.96,
CYSTINE-URINE,311875,CDM,300,RC,82131,HCPCS,Outpatient,,,53,37.1,,15.63,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,50.4,Percent of Total Billed Charges,50% of Total Billed Charges,45.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,45.96,
DIAZEPAM-SERUM,311889,CDM,300,RC,80346,HCPCS,Outpatient,,,59,41.3,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,40.12,
DIRECT LDL,311890,CDM,300,RC,83721,HCPCS,Outpatient,,,30,21,,7.14,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,21,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,21,
MOLECULAR AMPLIFICATION 2 SEQ,311895,CDM,300,RC,81256,HCPCS,Outpatient,,,106,74.2,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,72.08,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,53,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,130.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,53,130.72,
NUCLEIC ACID HIGH RESOLUTE,311896,CDM,300,RC,81256,HCPCS,Outpatient,,,53,37.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,223.6,Percent of Total Billed Charges,50% of Total Billed Charges,130.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,130.72,
MUTATION IDENTIFICATION,311897,CDM,300,RC,87522,HCPCS,Outpatient,,,53,37.1,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,441.18,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,107.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,85.68,
CYSTIC FIBROSIS PROFILE-DNA,311900,CDM,300,RC,81220,HCPCS,Outpatient,,,229,160.3,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,155.72,68,,124.58,Percent of Total Billed Charges,68% of Total Billed Charges,155.72,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,114.5,50,,605.2,Percent of Total Billed Charges,50% of Total Billed Charges,1113.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,751.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,556.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,114.5,1113.2,
MOLECULAR DIAG-ISOLATION OR EX,311901,CDM,300,RC,83890,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,324.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-SEPR/GEL ELECTR,311902,CDM,300,RC,83894,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,28.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-AMPLIF OF NUCLE,311903,CDM,300,RC,83901,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,28.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-INTERPRETATION,311904,CDM,300,RC,81256,HCPCS,Outpatient,,,13,9.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,257.31,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,130.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,130.72,
MOLECULAR DIAG-ISO/EXTR PURFD,311905,CDM,300,RC,81256,HCPCS,Outpatient,,,13,9.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,294.85,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,130.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6.5,130.72,
MOLECULAR DIAG-ENZYMATIC DIGES,311906,CDM,300,RC,83892,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,140.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-AMP NUC ACID-SN,311907,CDM,300,RC,83898,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-SEP GEL ELECTRO,311908,CDM,300,RC,83894,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-ENZY DIGEST,311909,CDM,300,RC,83892,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,69.63,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-SEP GEL ELECTRO,311910,CDM,300,RC,83894,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,21.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-NUCLEIC ACID PR,311911,CDM,300,RC,83896,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MOLECULAR DIAG-NUCLEIC ACID TR,311912,CDM,300,RC,83897,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MLH1 CPMPREHENSIVE,311913,CDM,300,RC,81292,HCPCS,Outpatient,1,ML,2431,1701.7,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,1653.08,68,,1322.46,Percent of Total Billed Charges,68% of Total Billed Charges,1653.08,68,,82.69,Percent of Total Billed Charges,68% of Total Billed Charges,1215.5,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,1350.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,911.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,675.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,675.4,100,,,Fee Schedule,100% of CMS OPPS Rate,675.4,1653.08,
RUSSELL SILVER SYNDROME METHYL,311914,CDM,300,RC,81401,HCPCS,Outpatient,,,416,291.2,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,282.88,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,282.88,68,,121.31,Percent of Total Billed Charges,68% of Total Billed Charges,208,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,274,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,282.88,
RUSSELL SILVER SYNDROME UPD ST,311915,CDM,300,RC,81402,HCPCS,Outpatient,,,416,291.2,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,282.88,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,282.88,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,208,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,300.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,150.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,300.66,
DEHYDROEPIANDROSTENE SULFATE,311920,CDM,300,RC,82627,HCPCS,Outpatient,,,71,49.7,,15.12,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,44.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.23,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,48.28,
DEHYDROEPIANDROSTERONE (DHEA),311925,CDM,300,RC,82626,HCPCS,Outpatient,,,80,56,,17.18,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,54.4,
HEREDITARY HEMACHROMATOSIS DNA,311930,CDM,300,RC,81256,HCPCS,Outpatient,,,424,296.8,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,288.32,68,,230.66,Percent of Total Billed Charges,68% of Total Billed Charges,288.32,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,212,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,130.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,288.32,
DILANTIN,311950,CDM,300,RC,80185,HCPCS,Outpatient,,,42,29.4,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,277.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,28.56,
DESIPRAMINE LEVEL,311975,CDM,300,RC,80160,HCPCS,Outpatient,,,54,37.8,,,,,,Other,Not Seperately Reimbusable,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,153.95,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,196.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,36.72,
DEXAMETHASONE,311976,CDM,300,RC,80299,HCPCS,Outpatient,,,98,68.6,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,66.64,68,,53.31,Percent of Total Billed Charges,68% of Total Billed Charges,66.64,68,,294.85,Percent of Total Billed Charges,68% of Total Billed Charges,49,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,66.64,
EB VIRUS-ERLY ANT/EA,311980,CDM,300,RC,86663,HCPCS,Outpatient,,,42,29.4,,8.92,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,28.56,
EB VIR-NUCL ANT-EBNA,311981,CDM,300,RC,86664,HCPCS,Outpatient,,,49,34.3,,10.4,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,33.32,
EB VIR-VIR CAPSID,311982,CDM,300,RC,86665,HCPCS,Outpatient,,,58,40.6,,12.34,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,39.44,
EBV BY PCR QUANTITATIVE,311983,CDM,300,RC,87798,HCPCS,Outpatient,,,255,178.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,173.4,68,,138.72,Percent of Total Billed Charges,68% of Total Billed Charges,173.4,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,127.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,173.4,
ENA & DNA/DS & ANTICH & CENT,311985,CDM,300,RC,86225,HCPCS,Outpatient,,,756,529.2,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,514.08,68,,411.26,Percent of Total Billed Charges,68% of Total Billed Charges,514.08,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,378,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,514.08,
EHRLICHIA ANTIBODY (IFA TECHNI,311990,CDM,300,RC,86666,HCPCS,Outpatient,,,20,14,,6.92,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10,20.36,
ELECTROLYTE PANEL,311995,CDM,300,RC,80051,HCPCS,Outpatient,,,22,15.4,,4.77,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,14.96,
ERYTHROPOIETIN,311997,CDM,300,RC,82668,HCPCS,Outpatient,,,60,42,,12.78,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.79,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,40.8,
ESTERONE,311998,CDM,300,RC,82679,HCPCS,Outpatient,,,80,56,,16.97,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,54.4,
ESTRADIOL,312000,CDM,300,RC,82670,HCPCS,Outpatient,,,88,61.6,,19,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,59.84,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,44,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,55.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,59.84,
ESTRADIOL FREE,312010,CDM,300,RC,82670,HCPCS,Outpatient,,,325,227.5,,19,100,,,fee schedule,100% Aetna Market fee schedule,221,68,,176.8,Percent of Total Billed Charges,68% of Total Billed Charges,221,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,162.5,50,,78.4,Percent of Total Billed Charges,50% of Total Billed Charges,55.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,221,
ESTROGENS-TOTAL,312020,CDM,300,RC,82672,HCPCS,Outpatient,,,69,48.3,,14.76,100,,,fee schedule,100% Aetna Market fee schedule,46.92,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,46.92,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,34.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,43.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,46.92,
ETHYLENE GLYCOL,312040,CDM,300,RC,82693,HCPCS,Outpatient,,,48,33.6,,10.13,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,32.64,
ACCU-CHECK BLOOD SUGAR,312050,CDM,300,RC,82948,HCPCS,Outpatient,,,10,7,,3.43,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5,10.08,
FECAL ALPHA-1 ANTITRYPSIN,312052,CDM,300,RC,82103,HCPCS,Outpatient,,,42,29.4,,9.14,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,28.56,
FECAL FAT-QUAL,312055,CDM,300,RC,82705,HCPCS,Outpatient,,,39,27.3,,3.47,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.19,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.1,100,,,Fee Schedule,100% of CMS OPPS Rate,5.1,26.52,
FECAL FAT-QUANT,312060,CDM,300,RC,82710,HCPCS,Outpatient,,,20,14,,11.42,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,81.06,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,33.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10,33.6,
FECAL REDUC SUBSTANC,312065,CDM,300,RC,84999,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,57.8,
ETHOSUXIMIDE LEVEL,312070,CDM,300,RC,80168,HCPCS,Outpatient,,,52,36.4,,11.11,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,35.36,
FERRITIN,312073,CDM,300,RC,82728,HCPCS,Outpatient,,,43,30.1,,9.27,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,29.24,
FLECAINIDE-TAMBOCOR,312080,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
FOLIC ACID-RBC,312090,CDM,300,RC,82747,HCPCS,Outpatient,,,55,38.5,,12,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.29,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate,17.65,37.4,
FELBATOL,312095,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
FOLLICLE STIM HORMON,312100,CDM,300,RC,83001,HCPCS,Outpatient,,,59,41.3,,12.63,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,37.15,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.58,100,,,Fee Schedule,100% of CMS OPPS Rate,18.58,40.12,
PHENYTOIN-FREE,312110,CDM,300,RC,80186,HCPCS,Outpatient,,,43,30.1,,9.36,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,290.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.76,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,29.24,
FREE T-3,312120,CDM,300,RC,84481,HCPCS,Outpatient,,,72,50.4,,11.52,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,30.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,48.96,
FREE T-4,312125,CDM,300,RC,84439,HCPCS,Outpatient,,,29,20.3,,6.13,100,,,fee schedule,100% Aetna Market fee schedule,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.72,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,14.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,18.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,19.72,
FRUCTOSAMINE,312130,CDM,300,RC,82985,HCPCS,Outpatient,,,48,33.6,,11.4,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.76,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,33.52,
IONIZE CA,312160,CDM,300,RC,82330,HCPCS,Outpatient,,,43,30.1,,9.3,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,13.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.68,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,29.24,
G6PD (GLUC 6-PHOS DHY) QUANT,312190,CDM,300,RC,82955,HCPCS,Outpatient,,,31,21.7,,6.6,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,21.08,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,15.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,19.39,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.7,100,,,Fee Schedule,100% of CMS OPPS Rate,9.7,21.08,
GAMMA GLUTAMUL TRAN.,312200,CDM,300,RC,82977,HCPCS,Outpatient,,,24,16.8,,4.9,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,16.32,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,12,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,16.32,
GABAPENTIN (NEURONTIN),312225,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
GASTRIC OCCULT BLOOD,312240,CDM,300,RC,82271,HCPCS,Outpatient,,,10,7,,3.62,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5,10.64,
GASTRIN-SERUM,312255,CDM,300,RC,82941,HCPCS,Outpatient,,,57,39.9,,11.99,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,38.76,
GENTAMYCIN,312260,CDM,300,RC,80170,HCPCS,Outpatient,,,52,36.4,,11.14,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,35.36,
HYDROCODONE LEVEL,312265,CDM,300,RC,82646,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,304.1,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,44.2,
GAD-65,312270,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
GADOLINIUM,312275,CDM,300,RC,83018,HCPCS,Outpatient,,,271,189.7,,14.93,100,,,fee schedule,100% Aetna Market fee schedule,184.28,68,,147.42,Percent of Total Billed Charges,68% of Total Billed Charges,184.28,68,,823.07,Percent of Total Billed Charges,68% of Total Billed Charges,135.5,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,43.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,184.28,
GENERAL HEALTH PANEL,312295,CDM,300,RC,80050,HCPCS,Outpatient,,,279,195.3,,26.63,100,,,fee schedule,100% Aetna Market fee schedule,189.72,68,,151.78,Percent of Total Billed Charges,68% of Total Billed Charges,189.72,68,,441.18,Percent of Total Billed Charges,68% of Total Billed Charges,139.5,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.5,189.72,
GLUCOSE-QUANT,312300,CDM,300,RC,82947,HCPCS,Outpatient,,,13,9.1,,2.67,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,8.84,
GLUCAGON,312310,CDM,300,RC,82943,HCPCS,Outpatient,,,44,30.8,,9.72,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,29.92,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,22,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,29.92,
GLUCOSE-BODY FLUID,312320,CDM,300,RC,82945,HCPCS,Outpatient,,,13,9.1,,2.67,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,8.84,
GLUCOSE TOL.FASTING-3 SPEC,312350,CDM,300,RC,82951,HCPCS,Outpatient,,,41,28.7,,8.75,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,27.88,
GLUCOSE (EACH BEYOND 3 SPEC-GT,312351,CDM,300,RC,82952,HCPCS,Outpatient,,,13,9.1,,2.67,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,7.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,8.84,
50GM GLUCOSE CHALLEN/2HR-PP,312352,CDM,300,RC,82950,HCPCS,Outpatient,,,16,11.2,,3.23,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,10.88,
GM 1 ANTIBODY,312355,CDM,300,RC,83516,HCPCS,Outpatient,,,77,53.9,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,52.36,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,38.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,52.36,
GASTROINTESTINAL PANEL (PCR) S,312370,CDM,300,RC,87507,HCPCS,Outpatient,,,231,161.7,,283.41,100,,,fee schedule,100% Aetna Market fee schedule,157.08,68,,125.66,Percent of Total Billed Charges,68% of Total Billed Charges,157.08,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,115.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,833.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,115.5,833.56,
AST (SGOT),312400,CDM,300,RC,84450,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
ALT (SGPT),312450,CDM,300,RC,84460,HCPCS,Outpatient,,,17,11.9,,3.6,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,10.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,11.56,
HAPTOGLOBIN-QUANT,312500,CDM,300,RC,83010,HCPCS,Outpatient,,,40,28,,8.55,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,25.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,27.2,
SERUM PREGNANCY TEST,312525,CDM,300,RC,84703,HCPCS,Outpatient,,,25,17.5,,5.11,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,15.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,17,
HDL CHOLESTEROL,312550,CDM,300,RC,83718,HCPCS,Outpatient,,,26,18.2,,5.57,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,16.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,17.68,
HEAVY METALS SCREEN-URINE,312575,CDM,300,RC,83015,HCPCS,Outpatient,,,60,42,,14.24,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS Rate,20.94,41.88,
HEAT STABLE ALK PHOS,312600,CDM,300,RC,84078,HCPCS,Outpatient,,,18,12.6,,5.62,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.26,100,,,Fee Schedule,100% of CMS OPPS Rate,8.26,16.52,
HEAVY METALS SCREEN-BLOOD,312625,CDM,300,RC,83015,HCPCS,Outpatient,,,60,42,,14.24,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,41.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.94,100,,,Fee Schedule,100% of CMS OPPS Rate,20.94,41.88,
HEMOGLOBIN A I C,312650,CDM,300,RC,83036,HCPCS,Outpatient,,,31,21.7,,6.6,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,21.08,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,15.5,50,,27.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,21.08,
HEMOGLOBIN FRACTIONATION,312700,CDM,300,RC,83020,HCPCS,Outpatient,,,41,28.7,,8.75,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,376.99,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,27.88,
HEPATIC FUNCTION-LFT,312720,CDM,300,RC,80076,HCPCS,Outpatient,,,26,18.2,,5.56,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,267.65,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,17.68,
"HLA-DQA1, DQB1",312725,CDM,300,RC,81376,HCPCS,Outpatient,,,638,446.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,433.84,68,,347.07,Percent of Total Billed Charges,68% of Total Billed Charges,433.84,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,319,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,244.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,122.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,433.84,
HEPATITIS PANEL,312730,CDM,300,RC,80074,HCPCS,Outpatient,,,150,105,,32.39,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,102,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,75,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,95.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,47.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,102,
HETEROPHILE ANTIBODY,312740,CDM,300,RC,86309,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
HISTOPLASMA-AB,312745,CDM,300,RC,86698,HCPCS,Outpatient,,,40,28,,9.38,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.79,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,27.58,
H.PYLORI QUANTITATIVE ANTIBODY,312748,CDM,300,RC,87339,HCPCS,Outpatient,,,38,26.6,,10.88,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,100,,,Fee Schedule,100% of CMS OPPS Rate,16,32,
HLA B-27,312750,CDM,300,RC,86812,HCPCS,Outpatient,,,82,57.4,,17.55,100,,,fee schedule,100% Aetna Market fee schedule,55.76,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,55.76,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,41,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,51.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,55.76,
HOMOCYSTINE LEVEL,312760,CDM,300,RC,83090,HCPCS,Outpatient,,,53,37.1,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,35.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,36.04,
HSV II ANTIBODY-IGG,312782,CDM,300,RC,86696,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
LATEX SPECIFIC AB IGE,312790,CDM,300,RC,86003,HCPCS,Outpatient,,,17,11.9,,3.55,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,10.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,11.56,
LE PREP (LEUKOCYTE PHAGOCYTOSI,312800,CDM,300,RC,86344,HCPCS,Outpatient,,,26,18.2,,7.07,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.39,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,20.78,
LIVER/KIDNEY MICROSOMAL AB,312815,CDM,300,RC,86376,HCPCS,Outpatient,,,47,32.9,,9.89,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,31.96,
ICA-512,312825,CDM,300,RC,86341,HCPCS,Outpatient,,,37,25.9,,16.03,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,47.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,47.14,
IFE/PE SERUM,312830,CDM,300,RC,82784,HCPCS,Outpatient,,,72,50.4,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,48.96,
IFE/PE URINE,312835,CDM,300,RC,84156,HCPCS,Outpatient,,,58,40.6,,2.5,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,7.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,39.44,
IG A,312850,CDM,300,RC,82784,HCPCS,Outpatient,,,18,12.6,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9,18.6,
IG D,312900,CDM,300,RC,82784,HCPCS,Outpatient,,,18,12.6,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9,18.6,
IG E-TOTAL,312950,CDM,300,RC,82785,HCPCS,Outpatient,,,52,36.4,,11.19,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,32.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,35.36,
IG G,313000,CDM,300,RC,82784,HCPCS,Outpatient,,,18,12.6,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9,18.6,
IGG QUANT CSF,313025,CDM,300,RC,82784,HCPCS,Outpatient,,,55,38.5,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,89.6,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,37.4,
IGG4 AUTOIMMUNE,313028,CDM,300,RC,82787,HCPCS,Outpatient,,,19,13.3,,5.45,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,16.04,
IG M,313050,CDM,300,RC,82784,HCPCS,Outpatient,,,18,12.6,,6.32,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9,18.6,
INSULIN-TOTAL,313057,CDM,300,RC,83525,HCPCS,Outpatient,,,37,25.9,,7.77,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.43,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,25.16,
IONTOPHORESIS-SWEAT COLLECTION,313061,CDM,300,RC,89230,HCPCS,Outpatient,,,58,40.6,,1.54,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,5.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,66.16,
IRON BINDING CAPACI.,313100,CDM,300,RC,83550,HCPCS,Outpatient,,,28,19.6,,5.94,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,77.6,Percent of Total Billed Charges,50% of Total Billed Charges,17.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,19.04,
CK-ISOENZYMES,313105,CDM,300,RC,82552,HCPCS,Outpatient,,,42,29.4,,9.11,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,28.56,
ISOPROPYL ALCOHOL,313125,CDM,300,RC,84600,HCPCS,Outpatient,,,51,35.7,,11.63,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,394.94,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,34.68,
JAK 2 (V617F) MUTATION ANALYSI,313135,CDM,300,RC,81270,HCPCS,Outpatient,,,1733,1213.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,1178.44,68,,942.75,Percent of Total Billed Charges,68% of Total Billed Charges,1178.44,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,866.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,183.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.66,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,1178.44,
KAPPA & LAMBDA FREE LIGHT CHAI,313140,CDM,300,RC,83883,HCPCS,Outpatient,,,107,74.9,,9.25,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,72.76,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,53.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,72.76,
KAPPA & LAMBDA URINE,313142,CDM,300,RC,83883,HCPCS,Outpatient,,,107,74.9,,9.25,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,72.76,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,53.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,27.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,72.76,
L/S RATIO,313148,CDM,300,RC,83661,HCPCS,Outpatient,,,70,49,,14.95,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,43.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,47.6,
LACTIC ACID,313150,CDM,300,RC,83605,HCPCS,Outpatient,,,52,36.4,,7.87,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,23.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,35.36,
LDH-SERUM,313200,CDM,300,RC,83615,HCPCS,Outpatient,,,19,13.3,,4.11,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,12.92,
L PNEUMOPHILIA-IGM,313260,CDM,300,RC,86713,HCPCS,Outpatient,,,49,34.3,,10.4,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,33.32,
L LONGBEACHAE-IGM,313261,CDM,300,RC,86713,HCPCS,Outpatient,,,49,34.3,,10.4,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,33.32,
ATYPICAL LEGIONELLA-IGM,313262,CDM,300,RC,86713,HCPCS,Outpatient,,,49,34.3,,10.4,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,33.32,
LAMICTAL (LAMOTRIGINE),313300,CDM,300,RC,80175,HCPCS,Outpatient,,,43,30.1,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,55.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,29.24,
LIDOCAINE -XYLOCAINE,313320,CDM,300,RC,80176,HCPCS,Outpatient,,,47,32.9,,9.99,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,29.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14.69,31.96,
LIPASE,313350,CDM,300,RC,83690,HCPCS,Outpatient,,,22,15.4,,4.69,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,13.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,14.96,
LIPID ELECTROPHORESI,313400,CDM,300,RC,83701,HCPCS,Outpatient,,,79,55.3,,23.02,100,,,fee schedule,100% Aetna Market fee schedule,53.72,68,,42.98,Percent of Total Billed Charges,68% of Total Billed Charges,53.72,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,39.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,67.72,
LIPOPROTEIN QUANT BY NMR,313402,CDM,300,RC,83704,HCPCS,Outpatient,,,119,83.3,,23.25,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,80.92,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,59.5,50,,77.6,Percent of Total Billed Charges,50% of Total Billed Charges,68.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,80.92,
LIPID PANEL,313420,CDM,300,RC,80061,HCPCS,Outpatient,,,42,29.4,,9.11,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,26.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,28.56,
APOLIPOPROTEIN,313480,CDM,300,RC,82172,HCPCS,Outpatient,,,49,34.3,,14.34,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,42.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,42.18,
LYSOZYME-SERUM,313500,CDM,300,RC,85549,HCPCS,Outpatient,,,60,42,,12.75,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,40.8,
LITHIUM,313550,CDM,300,RC,80178,HCPCS,Outpatient,,,21,14.7,,4.49,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,14.28,
LDH ISOENZYMES,313600,CDM,300,RC,83625,HCPCS,Outpatient,,,41,28.7,,8.7,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,25.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.79,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,27.88,
METOCLOPRAMIDE (REGLAN),313670,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
N-ACETYL PROCAINAMIDE,313675,CDM,300,RC,80192,HCPCS,Outpatient,,,53,37.1,,11.39,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.75,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,36.04,
LUTINIZING HORMONE,313700,CDM,300,RC,83002,HCPCS,Outpatient,,,59,41.3,,12.59,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,40.12,
MEGALOBLASTIC ANEMIA PROFILE,313725,CDM,300,RC,82136,HCPCS,Outpatient,,,53,37.1,,13.33,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,39.22,
MAGNESIUM,313750,CDM,300,RC,83735,HCPCS,Outpatient,,,21,14.7,,4.56,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,238.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,14.28,
MAGNESIUM-URINE,313755,CDM,300,RC,83735,HCPCS,Outpatient,,,21,14.7,,4.56,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,14.28,
MAPLE SYRUP URINE - MSUP,313760,CDM,300,RC,81205,HCPCS,Outpatient,,,351,245.7,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,238.68,68,,190.94,Percent of Total Billed Charges,68% of Total Billed Charges,238.68,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,175.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,189.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.99,100,,,Fee Schedule,100% of CMS OPPS Rate,94.99,238.68,
METHANOL ALCOHOL,313770,CDM,300,RC,84600,HCPCS,Outpatient,,,51,35.7,,11.63,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,34.68,
MANGANESE,313775,CDM,300,RC,83785,HCPCS,Outpatient,,,77,53.9,,18.12,100,,,fee schedule,100% Aetna Market fee schedule,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,52.36,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,38.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,53.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,53.3,
METHYLENETETRAHYDROFOLATE REDU,313790,CDM,300,RC,83894,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,66.91,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
MYOGLOBIN,313825,CDM,300,RC,83874,HCPCS,Outpatient,,,76,53.2,,8.79,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,51.68,
MYOGLOBIN QUANT-URINE,313849,CDM,300,RC,83874,HCPCS,Outpatient,,,76,53.2,,8.79,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,51.68,
NEONATE BILIRUBIN,313850,CDM,300,RC,82247,HCPCS,Outpatient,,,16,11.2,,3.41,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.03,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.02,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,10.88,
NEONATAL T-4,313860,CDM,300,RC,84437,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
OB PANEL,313870,CDM,300,RC,80055,HCPCS,Outpatient,,,178,124.6,,32.51,100,,,fee schedule,100% Aetna Market fee schedule,121.04,68,,96.83,Percent of Total Billed Charges,68% of Total Billed Charges,121.04,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,89,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,95.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,47.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,121.04,
NOREPINEPHRINE PLASMA,313875,CDM,300,RC,82384,HCPCS,Outpatient,,,80,56,,17.17,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,54.4,
OCCULT BLOOD SCREENING 1-3 TES,313900,CDM,300,RC,82270,HCPCS,Outpatient,,,10,7,,2.98,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,8.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,8.76,
OCCULT BLOOD-TRIPLE TEST,313905,CDM,300,RC,82272,HCPCS,Outpatient,,,10,7,,2.88,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,8.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.23,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,8.46,
"OLIGOCLONAL B,SERUM & CSF",313933,CDM,300,RC,83916,HCPCS,Outpatient,,,64,44.8,,18.63,100,,,fee schedule,100% Aetna Market fee schedule,43.52,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,43.52,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,54.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,54.78,
OLIGOCLONAL BANDING,313937,CDM,300,RC,83916,HCPCS,Outpatient,,,154,107.8,,18.63,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,104.72,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,77,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,54.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,104.72,
OPIATES,313940,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
OPIATE CONFIRMATION,313942,CDM,300,RC,80356,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
ORGANIC ACID QUALITATIVE URINE,313948,CDM,300,RC,83919,HCPCS,Outpatient,,,118,82.6,,11.19,100,,,fee schedule,100% Aetna Market fee schedule,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,80.24,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,59,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,80.24,
OSMOLARITY (SERUM),313950,CDM,300,RC,83930,HCPCS,Outpatient,,,21,14.7,,4.49,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,13.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,14.28,
OVA-1,313975,CDM,300,RC,84999,HCPCS,Outpatient,,,1073,751.1,,,,,,Other,Not Seperately Reimbusable,729.64,68,,583.71,Percent of Total Billed Charges,68% of Total Billed Charges,729.64,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,536.5,50,,11.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.5,729.64,
OSMOLALITY SERUM,313980,CDM,300,RC,83930,HCPCS,Outpatient,,,21,14.7,,4.49,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,14.28,
OSTEOCALCIN,313985,CDM,300,RC,83937,HCPCS,Outpatient,,,37,25.9,,20.3,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,59.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,59.7,
PARATHYROID HORMONE,314000,CDM,300,RC,83970,HCPCS,Outpatient,,,130,91,,28.07,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,82.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,41.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,88.4,
OXCARBAZEPINE (TRILEPTAL),314025,CDM,300,RC,82542,HCPCS,Outpatient,,,58,40.6,,16.38,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,90.85,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,48.18,
P C P,314041,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
PCP CONFIRMATION,314043,CDM,300,RC,83992,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,121.86,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,116.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
PHENOBARBITOL,314050,CDM,300,RC,80184,HCPCS,Outpatient,,,37,25.9,,10.4,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,30.6,
P2 Y12,314075,CDM,300,RC,81225,HCPCS,Outpatient,,,1444,1010.8,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,981.92,68,,785.54,Percent of Total Billed Charges,68% of Total Billed Charges,981.92,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,722,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,582.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,291.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.36,100,,,Fee Schedule,100% of CMS OPPS Rate,291.36,981.92,
PHOSPHATIDYLGLYCEROL,314090,CDM,300,RC,84081,HCPCS,Outpatient,,,52,36.4,,11.23,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.52,100,,,Fee Schedule,100% of CMS OPPS Rate,16.52,35.36,
PHOSPHOROUS,314100,CDM,300,RC,84100,HCPCS,Outpatient,,,16,11.2,,3.22,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,10.88,
PITUITARY EVAL PANEL,314115,CDM,300,RC,80418,HCPCS,Outpatient,,,231,161.7,,394.05,100,,,fee schedule,100% Aetna Market fee schedule,157.08,68,,125.66,Percent of Total Billed Charges,68% of Total Billed Charges,157.08,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,115.5,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,1158.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,579.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,579.48,100,,,Fee Schedule,100% of CMS OPPS Rate,115.5,1158.96,
PORPHOBILINOGIN-URINE 24HR,314125,CDM,300,RC,84110,HCPCS,Outpatient,,,209,146.3,,5.74,100,,,fee schedule,100% Aetna Market fee schedule,142.12,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,142.12,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,104.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,16.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,142.12,
PKU SCREEN,314128,CDM,300,RC,84030,HCPCS,Outpatient,,,103,72.1,,3.74,100,,,fee schedule,100% Aetna Market fee schedule,70.04,68,,56.03,Percent of Total Billed Charges,68% of Total Billed Charges,70.04,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,11,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,70.04,
PORPHYRINS-URINE FRACTIONATION,314130,CDM,300,RC,84120,HCPCS,Outpatient,,,209,146.3,,10,100,,,fee schedule,100% Aetna Market fee schedule,142.12,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,142.12,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,104.5,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,142.12,
POST PRANDIAL GLUCOSE,314150,CDM,300,RC,82950,HCPCS,Outpatient,,,16,11.2,,3.23,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,10.88,
POTASSIUM-SERUM,314200,CDM,300,RC,84132,HCPCS,Outpatient,,,15,10.5,,3.24,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.76,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,10.2,
POTASSIUM-STOOL,314205,CDM,300,RC,84999,HCPCS,Outpatient,,,153,107.1,,,,,,Other,Not Seperately Reimbusable,104.04,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,104.04,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,76.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,104.04,
POTASSIUM-URINE,314210,CDM,300,RC,84133,HCPCS,Outpatient,,,14,9.8,,3.22,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,9.52,
PREALUBUMIN (SERUM),314230,CDM,300,RC,84134,HCPCS,Outpatient,,,47,32.9,,9.92,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,29.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.59,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,31.96,
PROCALCITONIN (PCT),314240,CDM,300,RC,84145,HCPCS,Outpatient,,,288,201.6,,18.51,100,,,fee schedule,100% Aetna Market fee schedule,195.84,68,,156.67,Percent of Total Billed Charges,68% of Total Billed Charges,195.84,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,144,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,195.84,
PRIMIDONE,314250,CDM,300,RC,80188,HCPCS,Outpatient,,,53,37.1,,11.28,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,33.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.59,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,36.04,
PROGESTERONE,314270,CDM,300,RC,84144,HCPCS,Outpatient,,,66,46.2,,14.18,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,41.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,44.88,
PROINSULIN,314275,CDM,300,RC,84206,HCPCS,Outpatient,,,57,39.9,,18.15,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,75.62,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,53.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,53.38,
PROLACTIN,314280,CDM,300,RC,84146,HCPCS,Outpatient,,,62,43.4,,13.18,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,42.16,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,31,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,38.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,42.16,
PROTEIN-BODY FLUID,314310,CDM,300,RC,84157,HCPCS,Outpatient,,,13,9.1,,2.72,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,8.84,
PROT ELECTROPHORESIS W/INT CSF,314315,CDM,300,RC,84157,HCPCS,Outpatient,,,654,457.8,,2.72,100,,,fee schedule,100% Aetna Market fee schedule,444.72,68,,355.78,Percent of Total Billed Charges,68% of Total Billed Charges,444.72,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,327,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,444.72,
PROTEIN C - ANTIGEN,314320,CDM,300,RC,85302,HCPCS,Outpatient,,,38,26.6,,8.17,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,24.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,25.84,
PROTEIN C - FUNCTION,314325,CDM,300,RC,85303,HCPCS,Outpatient,,,110,77,,9.41,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,74.8,
PROTEIN S - TOTAL,314330,CDM,300,RC,85305,HCPCS,Outpatient,,,126,88.2,,7.89,100,,,fee schedule,100% Aetna Market fee schedule,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,85.68,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,63,50,,293.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,85.68,
PROTEIN S - FREE,314335,CDM,300,RC,85306,HCPCS,Outpatient,,,49,34.3,,10.42,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,188,Percent of Total Billed Charges,50% of Total Billed Charges,30.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,33.32,
PROTEIN S - FUNCTIONAL,314340,CDM,300,RC,85305,HCPCS,Outpatient,,,126,88.2,,7.89,100,,,fee schedule,100% Aetna Market fee schedule,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,85.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,63,50,,293.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,85.68,
PROTEIN ELECTROPHOR,314350,CDM,300,RC,84165,HCPCS,Outpatient,,,35,24.5,,7.3,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,23.8,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,23.8,
PSA TOTAL (DIAGNOSTIC),314380,CDM,300,RC,84153,HCPCS,Outpatient,,,59,41.3,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,137.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,40.12,
PSA SCREENING,314385,CDM,300,RC,G0103,HCPCS,Outpatient,,,59,41.3,,13.13,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,38.61,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.31,100,,,Fee Schedule,100% of CMS OPPS Rate,19.31,40.12,
PSA FREE & TOTAL,314390,CDM,300,RC,84154,HCPCS,Outpatient,,,59,41.3,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,36.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,40.12,
PSEUDOCHOLINESTERASE,314400,CDM,300,RC,82480,HCPCS,Outpatient,,,26,18.2,,5.35,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,15.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,17.68,
QUINIDINE-SERUM,314432,CDM,300,RC,80194,HCPCS,Outpatient,,,47,32.9,,9.93,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,324.22,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,29.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,31.96,
SEROQUIL (QUETIAPINE),314450,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,435.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
RAPAMYCIN (SIROLIMUS) LEVEL,314460,CDM,300,RC,80195,HCPCS,Outpatient,,,43,30.1,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,435.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,29.24,
RENIN,314467,CDM,300,RC,84244,HCPCS,Outpatient,,,70,49,,14.95,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,435.6,Percent of Total Billed Charges,50% of Total Billed Charges,43.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,47.6,
RISPERIDONE SERUM,314470,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,538.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
SACCHAROMYCES CEREVISIAE PANEL,314475,CDM,300,RC,86671,HCPCS,Outpatient,,,251,175.7,,8.33,100,,,fee schedule,100% Aetna Market fee schedule,170.68,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,170.68,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,125.5,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,170.68,
RISPERDAL LEVEL-SERUM,314480,CDM,300,RC,80299,HCPCS,Outpatient,,,345,241.5,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,234.6,68,,187.68,Percent of Total Billed Charges,68% of Total Billed Charges,234.6,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,172.5,50,,435.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,234.6,
"RISTOCETIN, COFACTOR ACTIVITY",314485,CDM,300,RC,85245,HCPCS,Outpatient,,,60,42,,15.6,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,352,Percent of Total Billed Charges,50% of Total Billed Charges,45.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,45.88,
SELENIUM,314490,CDM,300,RC,84255,HCPCS,Outpatient,,,81,56.7,,17.36,100,,,fee schedule,100% Aetna Market fee schedule,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,55.08,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,40.5,50,,854.8,Percent of Total Billed Charges,50% of Total Billed Charges,51.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,55.08,
RITALIN LEVEL-SERUM,314495,CDM,300,RC,82542,HCPCS,Outpatient,,,369,258.3,,16.38,100,,,fee schedule,100% Aetna Market fee schedule,250.92,68,,200.74,Percent of Total Billed Charges,68% of Total Billed Charges,250.92,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,184.5,50,,1364,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,250.92,
SERUM ACETONE,314550,CDM,300,RC,82009,HCPCS,Outpatient,,,15,10.5,,3.07,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,556,Percent of Total Billed Charges,50% of Total Billed Charges,9.03,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS Rate,4.52,10.2,
SERUM IRON,314600,CDM,300,RC,83540,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,572,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
T-TRANSGLUTAMINASE IGA (T-TGA),314610,CDM,300,RC,83516,HCPCS,Outpatient,,,39,27.3,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,390.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,26.52,
SODIUM-BODY FLUID,314640,CDM,300,RC,84302,HCPCS,Outpatient,,,11,7.7,,3.3,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.48,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,5.5,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,9.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,9.72,
SODIUM-SERUM,314650,CDM,300,RC,84295,HCPCS,Outpatient,,,16,11.2,,3.27,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,346.4,Percent of Total Billed Charges,50% of Total Billed Charges,9.61,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4.81,10.88,
SODIUM-STOOL,314655,CDM,300,RC,84302,HCPCS,Outpatient,,,153,107.1,,3.3,100,,,fee schedule,100% Aetna Market fee schedule,104.04,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,104.04,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,76.5,50,,320.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,104.04,
SODIUM-URINE,314660,CDM,300,RC,84300,HCPCS,Outpatient,,,11,7.7,,3.44,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.48,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,5.5,50,,1018.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.11,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.06,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,10.11,
SOLUBLE TRANSFERRIN REC,314670,CDM,300,RC,82397,HCPCS,Outpatient,,,41,28.7,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,28.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,28.24,
SUBOXONE (BUPRENORPHINE)SCREEN,314675,CDM,300,RC,83925,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,435.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
SOLUBLE LIVER AG (IGG AB),314677,CDM,300,RC,83516,HCPCS,Outpatient,,,163,114.1,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,110.84,68,,88.67,Percent of Total Billed Charges,68% of Total Billed Charges,110.84,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,81.5,50,,235.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,110.84,
SULFATE-URINE,314680,CDM,300,RC,84392,HCPCS,Outpatient,,,16,11.2,,3.73,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,572,Percent of Total Billed Charges,50% of Total Billed Charges,10.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,10.98,
OVA & PARISITES EXAM,314700,CDM,300,RC,87177,HCPCS,Outpatient,,,28,19.6,,6.05,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,278,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,19.04,
TOBRAMYCIN LEVEL,314706,CDM,300,RC,80200,HCPCS,Outpatient,,,51,35.7,,10.97,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,64.4,Percent of Total Billed Charges,50% of Total Billed Charges,32.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.13,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,34.68,
RENAL FUNCTION PANEL,314750,CDM,300,RC,80069,HCPCS,Outpatient,,,28,19.6,,5.9,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,512,Percent of Total Billed Charges,50% of Total Billed Charges,17.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.68,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,19.04,
SWEAT CHLORIDE,314762,CDM,300,RC,82438,HCPCS,Outpatient,,,16,11.2,,3.4,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,363.6,Percent of Total Billed Charges,50% of Total Billed Charges,10,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,10.88,
TOPAMAX (TOPIRAMATE),314765,CDM,300,RC,80201,HCPCS,Outpatient,,,38,26.6,,8.11,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,363.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,25.84,
T H C,314768,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,854.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
CANNABINOID CONFIRMATION,314769,CDM,300,RC,80349,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,158.85,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,363.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
TESTOSTERONE-TOTAL,314770,CDM,300,RC,84410,HCPCS,Outpatient,,,82,57.4,,34.87,100,,,fee schedule,100% Aetna Market fee schedule,55.76,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,55.76,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,41,50,,318.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,51.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41,102.56,
TESTOSTERONE FREE,314775,CDM,300,RC,84402,HCPCS,Outpatient,,,81,56.7,,17.32,100,,,fee schedule,100% Aetna Market fee schedule,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,55.08,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,40.5,50,,617.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,55.08,
B LYMPHOCYTES TOTAL,314780,CDM,300,RC,86355,HCPCS,Outpatient,,,59,41.3,,25.66,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,572,Percent of Total Billed Charges,50% of Total Billed Charges,75.45,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,29.5,75.45,
THYROGLOBULIN-QUAN,314785,CDM,300,RC,84432,HCPCS,Outpatient,,,51,35.7,,10.92,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,435.6,Percent of Total Billed Charges,50% of Total Billed Charges,32.11,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.06,100,,,Fee Schedule,100% of CMS OPPS Rate,16.06,34.68,
TBG THYROXINE BINDING GLOBULIN,314786,CDM,300,RC,84442,HCPCS,Outpatient,,,27,18.9,,10.05,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,256.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,29.56,
TOTAL PROTEIN-BODY FLUID,314790,CDM,300,RC,84157,HCPCS,Outpatient,,,13,9.1,,2.72,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,390.4,Percent of Total Billed Charges,50% of Total Billed Charges,8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,8.84,
THYROGLOBULIN AB,314792,CDM,300,RC,86800,HCPCS,Outpatient,,,51,35.7,,10.82,100,,,fee schedule,100% Aetna Market fee schedule,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,34.68,
T LYMPHOCYTES TOTAL,314795,CDM,300,RC,86359,HCPCS,Outpatient,,,59,41.3,,25.66,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,85.95,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,75.45,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,29.5,75.45,
PROTEIN-TOTAL,314800,CDM,300,RC,84155,HCPCS,Outpatient,,,13,9.1,,2.5,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,7.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,8.84,
CD4 COUNT,314805,CDM,300,RC,86361,HCPCS,Outpatient,,,66,46.2,,18.21,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,53.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,53.56,
T-CELLS-TOTAL,314810,CDM,300,RC,86359,HCPCS,Outpatient,,,59,41.3,,25.66,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,75.45,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,29.5,75.45,
CATECHOL-FRACTION,314815,CDM,300,RC,82384,HCPCS,Outpatient,,,80,56,,17.17,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,50.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,54.4,
TOXOPLASMA GONDI IGM,314820,CDM,300,RC,86778,HCPCS,Outpatient,,,76,53.2,,9.8,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,28.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,51.68,
TOXOPLASMOSIS IGG AB,314822,CDM,300,RC,86777,HCPCS,Outpatient,,,81,56.7,,9.79,100,,,fee schedule,100% Aetna Market fee schedule,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,55.08,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,40.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,55.08,
TP-PA,314825,CDM,300,RC,86780,HCPCS,Outpatient,,,42,29.4,,9,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,26.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,28.56,
TACROLIMUS,314830,CDM,300,RC,80197,HCPCS,Outpatient,,,43,30.1,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,27.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,29.24,
TRANSFERRIN,314840,CDM,300,RC,84466,HCPCS,Outpatient,,,41,28.7,,8.68,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,25.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.76,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,27.88,
TRAZODONE,314848,CDM,300,RC,80299,HCPCS,Outpatient,,,43,30.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,37.28,
TRIGLY CERIDES,314850,CDM,300,RC,84478,HCPCS,Outpatient,,,18,12.6,,3.9,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,11.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,12.24,
TROPONIN I-QUANT,314855,CDM,300,RC,84484,HCPCS,Outpatient,,,31,21.7,,8.48,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,21.08,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,15.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,24.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,24.94,
TRIIODOTHYRONINE T3 REVERSE,314875,CDM,300,RC,84482,HCPCS,Outpatient,,,50,35,,10.72,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,31.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.76,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,34,
TRYPTASE RIA,314880,CDM,300,RC,83520,HCPCS,Outpatient,,,190,133,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,129.2,68,,103.36,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,95,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,129.2,
URIC ACID-SERUM,314900,CDM,300,RC,84550,HCPCS,Outpatient,,,15,10.5,,3.07,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,399.3,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,9.03,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.52,100,,,Fee Schedule,100% of CMS OPPS Rate,4.52,10.2,
URINE URIC ACID,314905,CDM,300,RC,84560,HCPCS,Outpatient,,,15,10.5,,3.45,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,255.68,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,10.2,
URINE-5 HIAA-RANDOM,314907,CDM,300,RC,83497,HCPCS,Outpatient,,,96,67.2,,8.77,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,65.28,68,,399.3,Percent of Total Billed Charges,68% of Total Billed Charges,48,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,65.28,
URINE-GC&CHLAMYDIA W/TRICH,314908,CDM,300,RC,87491,HCPCS,Outpatient,,,88,61.6,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,59.84,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,44,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,70.18,
URIC ACID-BODY FLUID,314910,CDM,300,RC,84560,HCPCS,Outpatient,,,11,7.7,,3.45,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.48,68,,186.59,Percent of Total Billed Charges,68% of Total Billed Charges,5.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,10.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,10.16,
VAP CHOLESTEROL,314911,CDM,300,RC,83701,HCPCS,Outpatient,,,325,227.5,,23.02,100,,,fee schedule,100% Aetna Market fee schedule,221,68,,176.8,Percent of Total Billed Charges,68% of Total Billed Charges,221,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,162.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,221,
URINE ALDOSTERONE 24HR,314912,CDM,300,RC,82088,HCPCS,Outpatient,,,129,90.3,,27.71,100,,,fee schedule,100% Aetna Market fee schedule,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,87.72,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,64.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,81.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,87.72,
VARICELLA-ZOSTER IGG,314915,CDM,300,RC,86787,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
VARICELLA-ZOSTER IGM,314916,CDM,300,RC,86787,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,130.56,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,86,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
VITAMIN A LEVEL,314917,CDM,300,RC,84590,HCPCS,Outpatient,,,29,20.3,,7.89,100,,,fee schedule,100% Aetna Market fee schedule,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.72,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.5,50,,427.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,23.22,
VITAMIN B1 (THIAMINE),314918,CDM,300,RC,84425,HCPCS,Outpatient,,,44,30.8,,14.44,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,29.92,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,22,50,,73.6,Percent of Total Billed Charges,50% of Total Billed Charges,42.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.23,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,42.46,
URINE UREA,314919,CDM,300,RC,84540,HCPCS,Outpatient,,,21,14.7,,3.78,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,9884.8,Percent of Total Billed Charges,50% of Total Billed Charges,11.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,14.28,
VITAMIN B6,314920,CDM,300,RC,84207,HCPCS,Outpatient,,,44,30.8,,19.11,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,29.92,68,,732.22,Percent of Total Billed Charges,68% of Total Billed Charges,22,50,,1222,Percent of Total Billed Charges,50% of Total Billed Charges,56.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,22,56.2,
"UREA CLEARANCE, 24HR URINE",314921,CDM,300,RC,84545,HCPCS,Outpatient,,,28,19.6,,4.9,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,113.09,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,19.04,
URINE TOTAL VOLUME MEASURE,314922,CDM,300,RC,81050,HCPCS,Outpatient,,,10,7,,2.48,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,921.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,7.28,
URINE CITRATE-24HR,314923,CDM,300,RC,82507,HCPCS,Outpatient,,,88,61.6,,18.9,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,59.84,68,,478.72,Percent of Total Billed Charges,68% of Total Billed Charges,44,50,,1149.6,Percent of Total Billed Charges,50% of Total Billed Charges,55.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,59.84,
URINE OXALATE-24HR,314924,CDM,300,RC,83945,HCPCS,Outpatient,,,41,28.7,,9.83,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1162.53,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,247.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,28.9,
URINE PHOSPHORUS-24HR,314925,CDM,300,RC,84105,HCPCS,Outpatient,,,16,11.2,,3.93,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,1855.04,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,4493.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,11.56,
VALPROIC ACID LEVEL,314926,CDM,300,RC,80164,HCPCS,Outpatient,,,43,30.1,,9.21,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,756.16,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,852.8,Percent of Total Billed Charges,50% of Total Billed Charges,27.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,29.24,
VANCOMYCIN LEVEL,314927,CDM,300,RC,80202,HCPCS,Outpatient,,,43,30.1,,9.21,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,756.16,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,87.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,29.24,
VENOUS COLLECTION,314928,CDM,300,RC,36415,HCPCS,Outpatient,,,54,37.8,,2.04,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,36.72,
VIT B12 UNSAT. BIND,314929,CDM,300,RC,82608,HCPCS,Outpatient,,,46,32.2,,9.74,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,530.94,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,2516.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,31.28,
VIT D 25-HYDROXY (CALCIFEDIOL),314930,CDM,300,RC,82306,HCPCS,Outpatient,,,94,65.8,,20.13,100,,,fee schedule,100% Aetna Market fee schedule,63.92,68,,51.14,Percent of Total Billed Charges,68% of Total Billed Charges,63.92,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,47,50,,8470,Percent of Total Billed Charges,50% of Total Billed Charges,59.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,63.92,
SPECIMEN PROCESSING FEE,314931,CDM,300,RC,36415,HCPCS,Outpatient,,,17,11.9,,2.04,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,471.1,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,242,Percent of Total Billed Charges,50% of Total Billed Charges,17.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,17.66,
VITAMIN C,314932,CDM,300,RC,82180,HCPCS,Outpatient,,,28,19.6,,6.73,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,436.29,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,488.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,19.78,
VORICONAZOLE SERUM PLASMA,314933,CDM,300,RC,80299,HCPCS,Outpatient,,,422,295.4,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,286.96,68,,229.57,Percent of Total Billed Charges,68% of Total Billed Charges,286.96,68,,1385.57,Percent of Total Billed Charges,68% of Total Billed Charges,211,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,286.96,
VIT D 1.25 DIHYDROXY,314935,CDM,300,RC,82652,HCPCS,Outpatient,,,121,84.7,,26.18,100,,,fee schedule,100% Aetna Market fee schedule,82.28,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,82.28,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,60.5,50,,114.4,Percent of Total Billed Charges,50% of Total Billed Charges,77,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,82.28,
NU SWAB VAGINITIS PLUS,314936,CDM,300,RC,87661,HCPCS,Outpatient,,,673,471.1,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,457.64,68,,366.11,Percent of Total Billed Charges,68% of Total Billed Charges,457.64,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,336.5,50,,921.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,457.64,
VITAMIN E,314940,CDM,300,RC,84446,HCPCS,Outpatient,,,46,32.2,,9.64,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,320.42,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,28.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,31.28,
ZONISAMIDE LEVEL,314945,CDM,300,RC,80203,HCPCS,Outpatient,,,117,81.9,,9.01,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,79.56,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,58.5,50,,1064.8,Percent of Total Billed Charges,50% of Total Billed Charges,26.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,79.56,
VMA URINE,314950,CDM,300,RC,84585,HCPCS,Outpatient,,,49,34.3,,10.54,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,378.08,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,921.2,Percent of Total Billed Charges,50% of Total Billed Charges,31,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,33.32,
ZINC,315000,CDM,300,RC,84630,HCPCS,Outpatient,,,37,25.9,,7.75,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,97.89,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,22.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,25.16,
ZIKA VIRUS NAA COMPREHENSIVE,315100,CDM,300,RC,87798,HCPCS,Outpatient,,,845,591.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,574.6,68,,459.68,Percent of Total Billed Charges,68% of Total Billed Charges,574.6,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,422.5,50,,6677.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,574.6,
CELL BLOCK CYTOLOGY-INTERPRETA,321350,CDM,300,RC,88305,HCPCS,Outpatient,,,58,40.6,,22.36,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,494.5,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,642,Percent of Total Billed Charges,50% of Total Billed Charges,61.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.41,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,62.64,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,62.64,102,,,Fee Schedule,102% of MO Medicaid rate,61.41,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.41,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,29,66.16,
"PARACENTESIS-CYTOL,CONC,SMEAR-",321400,CDM,300,RC,88108,HCPCS,Outpatient,,,75,52.5,,15.03,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,433.02,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,172,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,59.61,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,59.61,102,,,Fee Schedule,102% of MO Medicaid rate,58.44,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,80.7,
"SPUTUM CYTOLOGY,CONC,SMEAR-INT",321450,CDM,300,RC,88108,HCPCS,Outpatient,,,75,52.5,,15.03,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,839.39,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,506.4,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,59.61,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,59.61,102,,,Fee Schedule,102% of MO Medicaid rate,58.44,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,80.7,
"THORACENTESIS CYTOL,CONC,SMEAR",321500,CDM,300,RC,88108,HCPCS,Outpatient,,,75,52.5,,15.03,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,553.2,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,59.61,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,59.61,102,,,Fee Schedule,102% of MO Medicaid rate,58.44,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,80.7,
URINE BK VIRUS BY PCR,321525,CDM,300,RC,87798,HCPCS,Outpatient,,,112,78.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,222.4,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,76.16,
URINE CYTOLOGY,321545,CDM,300,RC,88112,HCPCS,Outpatient,,,252,176.4,,18.53,100,,,fee schedule,100% Aetna Market fee schedule,171.36,68,,137.09,Percent of Total Billed Charges,68% of Total Billed Charges,171.36,68,,348.7,Percent of Total Billed Charges,68% of Total Billed Charges,126,50,,2216.8,Percent of Total Billed Charges,50% of Total Billed Charges,70.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.05,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,59.21,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,59.21,102,,,Fee Schedule,102% of MO Medicaid rate,58.05,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.05,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,49,171.36,
"URINE-CYTOLOGY CONC,SMEAR,INTE",321550,CDM,300,RC,88108,HCPCS,Outpatient,,,75,52.5,,15.03,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,530.94,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,336.8,Percent of Total Billed Charges,50% of Total Billed Charges,80.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,59.61,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,59.61,102,,,Fee Schedule,102% of MO Medicaid rate,58.44,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.44,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,80.7,
ACTIVATED CLOT TIME,330350,CDM,300,RC,85347,HCPCS,Outpatient,,,14,9.8,,2.91,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,819.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,9.52,
ACTIVATED PROTEIN RESISTANCE,330353,CDM,300,RC,85307,HCPCS,Outpatient,,,93,65.1,,10.42,100,,,fee schedule,100% Aetna Market fee schedule,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,63.24,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,46.5,50,,1029.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,63.24,
ANTITHROMBIN III FUNCT,330355,CDM,300,RC,85301,HCPCS,Outpatient,,,95,66.5,,7.35,100,,,fee schedule,100% Aetna Market fee schedule,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,68,,33.44,Percent of Total Billed Charges,68% of Total Billed Charges,47.5,50,,1155.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.81,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,64.6,
ALPHA GLOBIN GENE ANALYSIS,330360,CDM,300,RC,81257,HCPCS,Outpatient,,,718,502.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,488.24,68,,390.59,Percent of Total Billed Charges,68% of Total Billed Charges,488.24,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,359,50,,1364.8,Percent of Total Billed Charges,50% of Total Billed Charges,204.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,102.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,488.24,
ANTITHROMBIN III TOTAL,330370,CDM,300,RC,85300,HCPCS,Outpatient,,,95,66.5,,8.06,100,,,fee schedule,100% Aetna Market fee schedule,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,47.5,50,,1511.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,64.6,
BLEEDING TIME,330450,CDM,300,RC,85002,HCPCS,Outpatient,,,15,10.5,,3.28,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,1637.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.82,100,,,Fee Schedule,100% of CMS OPPS Rate,4.82,10.2,
BORDETELLA PERTUSSIS BY PCR,330475,CDM,300,RC,87798,HCPCS,Outpatient,,,293,205.1,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,199.24,68,,159.39,Percent of Total Billed Charges,68% of Total Billed Charges,199.24,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,146.5,50,,1847.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,199.24,
COAGULATION TIME,330500,CDM,300,RC,85348,HCPCS,Outpatient,,,9,6.3,,3.05,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.12,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,50,,1889.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.49,100,,,Fee Schedule,100% of CMS OPPS Rate,4.49,8.98,
CBC W/AUTO DIFF,330550,CDM,300,RC,85025,HCPCS,Outpatient,,,25,17.5,,5.28,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,1304.8,Percent of Total Billed Charges,50% of Total Billed Charges,15.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,17,
CBC W/MANUAL DIFF,330560,CDM,300,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,1245.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54,
D-DIMER QUANT,330588,CDM,300,RC,85379,HCPCS,Outpatient,,,32,22.4,,6.92,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,1245.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,21.76,
D-DIMER QUAL,330589,CDM,300,RC,85378,HCPCS,Outpatient,,,22,15.4,,6.61,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,19.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,19.44,
DIFFERENTIAL-BLOOD-MANUAL,330590,CDM,300,RC,85007,HCPCS,Outpatient,,,9,6.3,,2.58,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.12,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,7.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,7.6,
CBC W/MANUAL DIFF,330591,CDM,300,RC,85027,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,803.2,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
BODY FLUID CELL COUNT W/ MANUA,330600,CDM,300,RC,89051,HCPCS,Outpatient,,,18,12.6,,3.81,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,803.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,12.24,
FACTOR X ASSAY,330602,CDM,300,RC,85260,HCPCS,Outpatient,,,139,97.3,,12.17,100,,,fee schedule,100% Aetna Market fee schedule,94.52,68,,75.62,Percent of Total Billed Charges,68% of Total Billed Charges,94.52,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,69.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,17.9,94.52,
FACTOR XI ASSAY,330604,CDM,300,RC,85270,HCPCS,Outpatient,,,162,113.4,,12.17,100,,,fee schedule,100% Aetna Market fee schedule,110.16,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,110.16,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,81,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,17.9,110.16,
FACTOR XII ASSAY,330606,CDM,300,RC,85280,HCPCS,Outpatient,,,132,92.4,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,89.76,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,66,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,89.76,
FACTOR 5 LEIDEN,330610,CDM,300,RC,81241,HCPCS,Outpatient,,,990,693,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,673.2,68,,538.56,Percent of Total Billed Charges,68% of Total Billed Charges,673.2,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,495,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,146.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,73.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,673.2,
FACTOR 8 ASSAY,330613,CDM,300,RC,85240,HCPCS,Outpatient,,,80,56,,12.17,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,900.4,Percent of Total Billed Charges,50% of Total Billed Charges,35.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,17.9,54.4,
FACTOR 9 ASSAY,330617,CDM,300,RC,85250,HCPCS,Outpatient,,,97,67.9,,12.95,100,,,fee schedule,100% Aetna Market fee schedule,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,65.96,68,,57.76,Percent of Total Billed Charges,68% of Total Billed Charges,48.5,50,,488,Percent of Total Billed Charges,50% of Total Billed Charges,38.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,65.96,
VON WILDEBRAND FACTOR,330619,CDM,300,RC,85246,HCPCS,Outpatient,,,104,72.8,,15.6,100,,,fee schedule,100% Aetna Market fee schedule,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,70.72,68,,130.72,Percent of Total Billed Charges,68% of Total Billed Charges,52,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,45.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,70.72,
FDP-FIBRINOGEN DEG PROD,330620,CDM,300,RC,85362,HCPCS,Outpatient,,,80,56,,4.69,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,649.95,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,54.4,
FIBRINDEX,330625,CDM,300,RC,85384,HCPCS,Outpatient,,,29,20.3,,6.61,100,,,fee schedule,100% Aetna Market fee schedule,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.72,68,,111.87,Percent of Total Billed Charges,68% of Total Billed Charges,14.5,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,19.72,
VON WILDEBRAND PANEL,330630,CDM,300,RC,85246,HCPCS,Outpatient,,,637,445.9,,15.6,100,,,fee schedule,100% Aetna Market fee schedule,433.16,68,,346.53,Percent of Total Billed Charges,68% of Total Billed Charges,433.16,68,,15024.9,Percent of Total Billed Charges,68% of Total Billed Charges,318.5,50,,613.6,Percent of Total Billed Charges,50% of Total Billed Charges,45.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,433.16,
HEMATOCRIT,330650,CDM,300,RC,85014,HCPCS,Outpatient,,,8,5.6,,1.61,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,5.44,68,,375.74,Percent of Total Billed Charges,68% of Total Billed Charges,4,50,,2129.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,5.44,
HEMOGLOBIN,330700,CDM,300,RC,85018,HCPCS,Outpatient,,,8,5.6,,1.61,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,5.44,68,,6830.27,Percent of Total Billed Charges,68% of Total Billed Charges,4,50,,2952.4,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,5.44,
HTLV 1/2 ANTIBODY,330710,CDM,300,RC,86790,HCPCS,Outpatient,,,63,44.1,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,42.84,68,,1296.26,Percent of Total Billed Charges,68% of Total Billed Charges,31.5,50,,276.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,42.84,
LAP STAIN,330720,CDM,300,RC,85540,HCPCS,Outpatient,,,28,19.6,,5.85,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,133.15,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,17.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,19.04,
OSMATIC FRAGILITY,330740,CDM,300,RC,85555,HCPCS,Outpatient,,,21,14.7,,5.08,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,138.02,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,14.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.47,14.94,
PAR.THROMBOPLASTIN T,330750,CDM,300,RC,85730,HCPCS,Outpatient,,,19,13.3,,4.09,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,3825.54,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,12.92,
PLATELET FUNCTION TEST,330775,CDM,300,RC,85576,HCPCS,Outpatient,,,66,46.2,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,12874.4,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,49.82,
PLASMINOGEN,330795,CDM,300,RC,85420,HCPCS,Outpatient,,,140,98,,4.44,100,,,fee schedule,100% Aetna Market fee schedule,95.2,68,,76.16,Percent of Total Billed Charges,68% of Total Billed Charges,95.2,68,,367.84,Percent of Total Billed Charges,68% of Total Billed Charges,70,50,,528.8,Percent of Total Billed Charges,50% of Total Billed Charges,13.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,95.2,
PLATELET COUNT,330800,CDM,300,RC,85049,HCPCS,Outpatient,,,15,10.5,,3.05,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,742.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,8.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,10.2,
PRO-THROMBIN TIME,330850,CDM,300,RC,85610,HCPCS,Outpatient,,,13,9.1,,2.92,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,31.62,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,8.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,8.84,
"PROTHROMBIN ABS, IGC AND IGM",330851,CDM,300,RC,86849,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,63.24,68,,173.89,Percent of Total Billed Charges,68% of Total Billed Charges,46.5,50,,2487.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.5,63.24,
PROTHROMBIN G20210A MUTATION,330875,CDM,300,RC,81240,HCPCS,Outpatient,,,990,693,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,673.2,68,,538.56,Percent of Total Billed Charges,68% of Total Billed Charges,673.2,68,,1400.22,Percent of Total Billed Charges,68% of Total Billed Charges,495,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,131.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,673.2,
RBC,330900,CDM,300,RC,85041,HCPCS,Outpatient,,,9,6.3,,2.05,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.12,68,,81.47,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,50,,545.6,Percent of Total Billed Charges,50% of Total Billed Charges,6.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.02,100,,,Fee Schedule,100% of CMS OPPS Rate,3.02,6.12,
RBC UNIT SPLITTING,330950,CDM,300,RC,86985,HCPCS,Outpatient,,,40,28,,16.78,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,1618.5,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,4000,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,20,208.54,
CHROMIUM,331025,CDM,300,RC,82495,HCPCS,Outpatient,,,224,156.8,,13.79,100,,,fee schedule,100% Aetna Market fee schedule,152.32,68,,121.86,Percent of Total Billed Charges,68% of Total Billed Charges,152.32,68,,1400.22,Percent of Total Billed Charges,68% of Total Billed Charges,112,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,152.32,
CELL COUNT CSF,331050,CDM,300,RC,89050,HCPCS,Outpatient,,,9,6.3,,3.21,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.12,68,,15.2,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,50,,628.8,Percent of Total Billed Charges,50% of Total Billed Charges,9.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.5,9.44,
RETICULOCYTE COUNT,331100,CDM,300,RC,85045,HCPCS,Outpatient,,,13,9.1,,2.71,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,10149.95,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,255.6,Percent of Total Billed Charges,50% of Total Billed Charges,7.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,8.84,
SEDIMENTATION RATE,331150,CDM,300,RC,85651,HCPCS,Outpatient,,,11,7.7,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.48,68,,1025.09,Percent of Total Billed Charges,68% of Total Billed Charges,5.5,50,,60.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,8.53,
SICKLE DEX,331175,CDM,300,RC,85660,HCPCS,Outpatient,,,18,12.6,,3.75,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,4074.82,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,553.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,12.24,
SPERM COUNT,331200,CDM,300,RC,89320,HCPCS,Outpatient,,,39,27.3,,8.37,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,419.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,24.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12.31,26.52,
SPERM COUNT; POST VASECTOMY,331210,CDM,300,RC,89321,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,628.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
THROMBIN TIME,331230,CDM,300,RC,85670,HCPCS,Outpatient,,,66,46.2,,3.92,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,11.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,44.88,
VIPER VENOM TIME,331240,CDM,300,RC,85613,HCPCS,Outpatient,,,30,21,,6.51,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,19.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,20.4,
WBC,331252,CDM,300,RC,85048,HCPCS,Outpatient,,,8,5.6,,1.73,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,5.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,4,50,,1093.6,Percent of Total Billed Charges,50% of Total Billed Charges,5.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,5.44,
FIBROSURE,331270,CDM,300,RC,82172,HCPCS,Outpatient,,,578,404.6,,14.34,100,,,fee schedule,100% Aetna Market fee schedule,393.04,68,,314.43,Percent of Total Billed Charges,68% of Total Billed Charges,393.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,289,50,,2423.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,393.04,
FETAL FIBRONECTIN,331290,CDM,300,RC,82731,HCPCS,Outpatient,,,248,173.6,,43.8,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,2095.2,Percent of Total Billed Charges,50% of Total Billed Charges,128.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,168.64,
FLOW CYTOMETRY-1ST MARKER,331300,CDM,300,RC,88184,HCPCS,Outpatient,,,73,51.1,,44.71,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,49.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,36.5,50,,162.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,438.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,36.5,438.87,
FLOW CYTOMETRY-ADD. MARKER,331310,CDM,300,RC,88185,HCPCS,Outpatient,,,73,51.1,,14.32,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,49.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,36.5,50,,1245.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.6,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,49.64,
FLOW CYTOMETRY INTERPRETATION,331325,CDM,300,RC,88189,HCPCS,Outpatient,,,37,25.9,,56.37,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,74,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,74,
HEPATITIS C VIRAL LOAD,331330,CDM,300,RC,87522,HCPCS,Outpatient,,,137,95.9,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,93.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,68.5,50,,1393.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,93.16,
MERCURY (SERUM),331340,CDM,300,RC,83825,HCPCS,Outpatient,,,228,159.6,,11.06,100,,,fee schedule,100% Aetna Market fee schedule,155.04,68,,124.03,Percent of Total Billed Charges,68% of Total Billed Charges,155.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,114,50,,3768,Percent of Total Billed Charges,50% of Total Billed Charges,32.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,155.04,
ROM TESTING,331350,CDM,300,RC,84112,HCPCS,Outpatient,,,132,92.4,,66.71,100,,,fee schedule,100% Aetna Market fee schedule,89.76,68,,71.81,Percent of Total Billed Charges,68% of Total Billed Charges,89.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,66,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,196.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,66,196.22,
FRAGILE X DNA ANALYSIS,331400,CDM,300,RC,81243,HCPCS,Outpatient,,,503,352.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,342.04,68,,273.63,Percent of Total Billed Charges,68% of Total Billed Charges,342.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,251.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,114.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,57.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,342.04,
AMPL NUCLEIC ACID-EACH SEQUENC,331401,CDM,300,RC,83898,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,186.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
SEP & ID HIGH RESOLUTION TECH/,331402,CDM,300,RC,83912,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,46.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,8.84,
CALPROTECTIN FECAL,331420,CDM,300,RC,83993,HCPCS,Outpatient,,,770,539,,13.35,100,,,fee schedule,100% Aetna Market fee schedule,523.6,68,,418.88,Percent of Total Billed Charges,68% of Total Billed Charges,523.6,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,385,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,523.6,
LISTERIA,331430,CDM,300,RC,86609,HCPCS,Outpatient,,,574,401.8,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,390.32,68,,312.26,Percent of Total Billed Charges,68% of Total Billed Charges,390.32,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,287,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,390.32,
SCLERODERMA,331440,CDM,300,RC,86235,HCPCS,Outpatient,,,198,138.6,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,134.64,
PNEUMOCYSTIS CARINNI (PCP) SPE,331450,CDM,300,RC,88312,HCPCS,Outpatient,,,164,114.8,,17.61,100,,,fee schedule,100% Aetna Market fee schedule,111.52,68,,89.22,Percent of Total Billed Charges,68% of Total Billed Charges,111.52,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,82,50,,397.6,Percent of Total Billed Charges,50% of Total Billed Charges,149.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.62,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,97.53,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,97.53,102,,,Fee Schedule,102% of MO Medicaid rate,95.62,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.62,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,49,149.32,
DIGOXIN LEVEL,342350,CDM,300,RC,80162,HCPCS,Outpatient,,,42,29.4,,9.03,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,28.56,
SERUM FOLATE,342400,CDM,300,RC,82746,HCPCS,Outpatient,,,47,32.9,,10,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,1084,Percent of Total Billed Charges,50% of Total Billed Charges,29.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,31.96,
SERUM VITAMIN B-12,342450,CDM,300,RC,82607,HCPCS,Outpatient,,,48,33.6,,10.25,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,2487.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,32.64,
THEOPHYLLIN LEVEL,342500,CDM,300,RC,80198,HCPCS,Outpatient,,,46,32.2,,9.62,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,754,Percent of Total Billed Charges,50% of Total Billed Charges,28.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,31.28,
THYROID STIM.HORMONE,342550,CDM,300,RC,84443,HCPCS,Outpatient,,,53,37.1,,11.42,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,53.5,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,457.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,36.04,
T TRANSGLUTAMINASE IGA (SERUM),342560,CDM,300,RC,83516,HCPCS,Outpatient,,,33,23.1,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,11.55,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,1990.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,23.06,
T3 TOTAL,342600,CDM,300,RC,84480,HCPCS,Outpatient,,,46,32.2,,9.64,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,3866.4,Percent of Total Billed Charges,50% of Total Billed Charges,28.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,31.28,
T-UPTAKE,342650,CDM,300,RC,84479,HCPCS,Outpatient,,,21,14.7,,4.4,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,14.28,
T-4-TOTAL,342700,CDM,300,RC,84436,HCPCS,Outpatient,,,22,15.4,,4.67,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,1998.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,14.96,
BONE MARROW ASPIRATION,348350,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,927.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
COMPREH. DIAG. EXAM,348400,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,1144.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
CYTOLOGY,348450,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
DIAG. EXAM-LARGE,348500,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
DIAG. EXAM-SMALL,348550,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,2099.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
EST.RCP.ASSAY W/PGRA,348594,CDM,300,RC,84233,HCPCS,Outpatient,,,204,142.8,,59.76,100,,,fee schedule,100% Aetna Market fee schedule,138.72,68,,110.98,Percent of Total Billed Charges,68% of Total Billed Charges,138.72,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,102,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,175.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.88,100,,,Fee Schedule,100% of CMS OPPS Rate,87.88,175.76,
FROZEN SECTION,348650,CDM,300,RC,88331,HCPCS,Outpatient,,,191,133.7,,26.83,100,,,fee schedule,100% Aetna Market fee schedule,129.88,68,,103.9,Percent of Total Billed Charges,68% of Total Billed Charges,129.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,95.5,50,,839.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.72,100,,,Fee Schedule,100% of MO Medicaid Rate,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,88.45,102,,,Fee Schedule,102% MO Medicaid rate,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,88.45,102,,,Fee Schedule,102% of MO Medicaid rate,86.72,100,,,Fee Schedule,100% of MO Medicaid rate,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,86.72,100,,,Fee Schedule,100% of MO Medicaid Rate,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,208.54,
FROZEN SECT.DIAG.TRT,348653,CDM,300,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1084,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,30.75,
O.R. SPECIMENS,348800,CDM,300,RC,,,Outpatient,,,36,25.2,,,,,,Other,Not Seperately Reimbusable,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,24.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,18,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.4,65,,18.72,Percent of Total Billed Charges,65% of Total Billed Charges,27,75,,21.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,21.6,60,,17.28,Percent of Total Billed Charges,60% of Total Billed Charges,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.34,20.4,,5.87,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.2,20,,5.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.2,27,
O.R. SPEC.ADDITON.3,348850,CDM,300,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2487.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,30.75,
PAP SMEAR-PATHOLOGY,348900,CDM,300,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,3416.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,36,
SURG.PATH-GROSS EXAM,348950,CDM,300,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1723.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,30.75,
SURG.PATH-GROSS-MICR,348975,CDM,300,RC,,,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2099.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.65,65,,21.32,Percent of Total Billed Charges,65% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,24.6,60,,19.68,Percent of Total Billed Charges,60% of Total Billed Charges,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.36,20.4,,6.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.2,20,,6.56,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.2,30.75,
ASO TITER,360350,CDM,300,RC,86060,HCPCS,Outpatient,,,24,16.8,,4.96,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,16.32,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,12,50,,522,Percent of Total Billed Charges,50% of Total Billed Charges,14.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,16.32,
ASO SCREEN,360351,CDM,300,RC,86063,HCPCS,Outpatient,,,19,13.3,,3.92,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,447.2,Percent of Total Billed Charges,50% of Total Billed Charges,11.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,12.92,
HEP B SURFACE ANTIGE,360400,CDM,300,RC,87340,HCPCS,Outpatient,,,32,22.4,,7.02,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,21.76,
C-REACTIVE PROTEIN,360500,CDM,300,RC,86140,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,336.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
C-REACTIVE PROTEIN HS,360510,CDM,300,RC,86141,HCPCS,Outpatient,,,41,28.7,,8.81,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,462.8,Percent of Total Billed Charges,50% of Total Billed Charges,25.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,27.88,
COLD AGGLUTININS,360550,CDM,300,RC,86156,HCPCS,Outpatient,,,21,14.7,,5.49,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,14.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,10.5,50,,504.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,16.14,
COMPLEMENT FIXATION,360600,CDM,300,RC,86171,HCPCS,Outpatient,,,32,22.4,,6.81,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,609.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.01,100,,,Fee Schedule,100% of CMS OPPS Rate,10.01,21.76,
FEBRILE AGGLUTININS,360650,CDM,300,RC,86000,HCPCS,Outpatient,,,14,9.8,,4.75,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,735.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,13.96,
GANGLIOSIDE ASLALO GM1 AUTO AB,360690,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,882,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
GANGLIOSIDE GD1A AUTO AB,360692,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1007.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
GANGLIOSIDE GD1B AUTO AB,360694,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1133.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
GANGLIOSIDE GM1 AUTO AB,360696,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1260,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
GANGLIOSIDE GQ1B AUTO AB,360698,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1385.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
ANA,360700,CDM,300,RC,86038,HCPCS,Outpatient,,,39,27.3,,8.22,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,1511.6,Percent of Total Billed Charges,50% of Total Billed Charges,24.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,26.52,
CHLAMYDIA-DNA PROBE,360704,CDM,300,RC,87491,HCPCS,Outpatient,,,112,78.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,1637.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,76.16,
HCV GENOTYPE,360705,CDM,300,RC,87902,HCPCS,Outpatient,,,811,567.7,,175.07,100,,,fee schedule,100% Aetna Market fee schedule,551.48,68,,441.18,Percent of Total Billed Charges,68% of Total Billed Charges,551.48,68,,253.5,Percent of Total Billed Charges,68% of Total Billed Charges,405.5,50,,1763.2,Percent of Total Billed Charges,50% of Total Billed Charges,514.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,551.48,
N GONORR.-DNA PROBE,360706,CDM,300,RC,87591,HCPCS,Outpatient,,,112,78.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,294.4,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,76.16,
GROWTH HORMONE,360707,CDM,300,RC,83003,HCPCS,Outpatient,,,53,37.1,,11.34,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,33.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,36.04,
HELICOBACTER PYLORI AB,360708,CDM,300,RC,86677,HCPCS,Outpatient,,,47,32.9,,11.46,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,3352.8,Percent of Total Billed Charges,50% of Total Billed Charges,33.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,33.7,
CHROMATIN AB IGG,360709,CDM,300,RC,82516,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,2414.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,13.6,
HBV BY PCR-QUANT,360710,CDM,300,RC,87517,HCPCS,Outpatient,,,473,331.1,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,321.64,68,,257.31,Percent of Total Billed Charges,68% of Total Billed Charges,321.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,236.5,50,,3416.8,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,321.64,
RESPIRATORY VIRUS PANEL,360711,CDM,300,RC,87633,HCPCS,Outpatient,,,542,379.4,,283.41,100,,,fee schedule,100% Aetna Market fee schedule,368.56,68,,294.85,Percent of Total Billed Charges,68% of Total Billed Charges,368.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,271,50,,560,Percent of Total Billed Charges,50% of Total Billed Charges,833.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,562.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,271,833.56,
CHLAMYDIA PNEUMONIAE PCR,360712,CDM,300,RC,87486,HCPCS,Outpatient,,,258,180.6,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,175.44,68,,140.35,Percent of Total Billed Charges,68% of Total Billed Charges,175.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,129,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,175.44,
VITAMIN K1,360713,CDM,300,RC,84597,HCPCS,Outpatient,,,75,52.5,,9.33,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,51,
VITAMIN B2,360714,CDM,300,RC,84252,HCPCS,Outpatient,,,68,47.6,,13.76,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,46.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,34,50,,445.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.47,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.24,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,46.24,
VITAMIN B3,360715,CDM,300,RC,83520,HCPCS,Outpatient,,,128,89.6,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,87.04,68,,69.63,Percent of Total Billed Charges,68% of Total Billed Charges,87.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,64,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,87.04,
IODINE,360716,CDM,300,RC,83018,HCPCS,Outpatient,,,71,49.7,,14.93,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,2194.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,48.28,
COENZYME Q10,360717,CDM,300,RC,82542,HCPCS,Outpatient,,,416,291.2,,16.38,100,,,fee schedule,100% Aetna Market fee schedule,282.88,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,282.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,208,50,,1113.6,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,282.88,
CHLAMYDIA PNEUMONIAE IGG,360718,CDM,300,RC,86631,HCPCS,Outpatient,,,71,49.7,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,705.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,48.28,
HCV NUCLEIC ACID AMPLIFICATION,360720,CDM,300,RC,87521,HCPCS,Outpatient,,,152,106.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,103.36,68,,82.69,Percent of Total Billed Charges,68% of Total Billed Charges,103.36,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,76,50,,90.4,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,103.36,
GONOR/CHLAMYDIA DNA PROBE,360721,CDM,300,RC,87801,HCPCS,Outpatient,,,223,156.1,,47.74,100,,,fee schedule,100% Aetna Market fee schedule,151.64,68,,121.31,Percent of Total Billed Charges,68% of Total Billed Charges,151.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,111.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,140.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.2,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,151.64,
HCV NUCLEIC ACID AMP W REFLEX,360725,CDM,300,RC,87902,HCPCS,Outpatient,,,319,223.3,,175.07,100,,,fee schedule,100% Aetna Market fee schedule,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,563.2,Percent of Total Billed Charges,50% of Total Billed Charges,514.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,159.5,514.9,
FTA-ABS,360740,CDM,300,RC,86780,HCPCS,Outpatient,,,42,29.4,,9,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,803.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,28.56,
FTA-T.PALL-CONF,360750,CDM,300,RC,86780,HCPCS,Outpatient,,,42,29.4,,9,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,803.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,28.56,
GONOCOCCAL AB,360760,CDM,300,RC,86609,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2487.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
COVID-19 ANTIGEN,360761,CDM,300,RC,87635,HCPCS,Outpatient,,,153,107.1,,51.31,100,,,fee schedule,100% Aetna Market fee schedule,104.04,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,104.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,76.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,69.27,135,,,Fee Schedule,135% of CMS OPPS Rate,37.68,102,,,Fee Schedule,102% MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS rate,37.68,102,,,Fee Schedule,102% of MO Medicaid rate,36.94,100,,,Fee Schedule,100% of MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,36.94,104.04,
HEP A AB IGM,360781,CDM,300,RC,86709,HCPCS,Outpatient,,,48,33.6,,7.66,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,22.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,32.64,
HEP A AB-TOTAL,360782,CDM,300,RC,86708,HCPCS,Outpatient,,,48,33.6,,8.43,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,24.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,32.64,
HEP B CORE AB-IGM,360783,CDM,300,RC,86705,HCPCS,Outpatient,,,48,33.6,,8,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,1245.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,32.64,
HEP B CORE AB-TOTAL,360784,CDM,300,RC,86704,HCPCS,Outpatient,,,48,33.6,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,32.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,24,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,32.64,
HEP B SURFACE AB,360785,CDM,300,RC,86706,HCPCS,Outpatient,,,35,24.5,,7.3,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,23.8,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,50,,3531.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,23.8,
HEP BE ANTIBODY,360786,CDM,300,RC,86707,HCPCS,Outpatient,,,37,25.9,,7.87,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,216.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,25.16,
HEP BE ANTIGEN,360787,CDM,300,RC,87350,HCPCS,Outpatient,,,37,25.9,,7.84,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,972.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,25.16,
HEP C AB,360788,CDM,300,RC,86803,HCPCS,Outpatient,,,46,32.2,,9.7,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,508.4,Percent of Total Billed Charges,50% of Total Billed Charges,28.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,31.28,
HEP C-RIB A,360789,CDM,300,RC,86804,HCPCS,Outpatient,,,49,34.3,,10.53,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,423.6,Percent of Total Billed Charges,50% of Total Billed Charges,30.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,33.32,
HEPATITIS DELTA ANTI,360790,CDM,300,RC,86692,HCPCS,Outpatient,,,54,37.8,,11.67,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,3796.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.16,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,36.72,
HEP C RNA QUANT,360791,CDM,300,RC,87522,HCPCS,Outpatient,,,149,104.3,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,101.32,68,,81.06,Percent of Total Billed Charges,68% of Total Billed Charges,101.32,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,74.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,101.32,
HIV I ANTIBODY,360792,CDM,300,RC,86701,HCPCS,Outpatient,,,28,19.6,,6.05,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,17.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,19.04,
HIV RNA BY PCR,360793,CDM,300,RC,87536,HCPCS,Outpatient,,,269,188.3,,57.87,100,,,fee schedule,100% Aetna Market fee schedule,182.92,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,182.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,134.5,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,170.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,182.92,
HIV I/II AB/AG,360795,CDM,300,RC,87389,HCPCS,Outpatient,,,61,42.7,,16.37,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,412,Percent of Total Billed Charges,50% of Total Billed Charges,48.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,48.16,
HIV BY PCR,360796,CDM,300,RC,87535,HCPCS,Outpatient,,,275,192.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,187,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,137.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,187,
HEP B SUPER QUANT PCR,360797,CDM,300,RC,87517,HCPCS,Outpatient,,,136,95.2,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,92.48,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,92.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,68,50,,1245.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,92.48,
HEPARIN ASSAY,360798,CDM,300,RC,85520,HCPCS,Outpatient,,,27,18.9,,8.9,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,18.36,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,13.5,50,,294.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,26.18,
HSV-I  IGM,360800,CDM,300,RC,86695,HCPCS,Outpatient,,,42,29.4,,8.97,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,1469.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,28.56,
HSV-I IGG,360805,CDM,300,RC,86695,HCPCS,Outpatient,,,42,29.4,,8.97,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.81,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,28.56,
HSV-I/II IGM,360807,CDM,300,RC,86694,HCPCS,Outpatient,,,46,32.2,,9.79,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,31.28,
HSV-II  IGM,360810,CDM,300,RC,86696,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,244,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
HSV-II  IGG,360815,CDM,300,RC,86696,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
HSV-I/II  IGG,360820,CDM,300,RC,86694,HCPCS,Outpatient,,,46,32.2,,9.79,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,504,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,31.28,
HSV-I/II DNA BY PCR,360822,CDM,300,RC,87530,HCPCS,Outpatient,,,136,95.2,,29.13,100,,,fee schedule,100% Aetna Market fee schedule,92.48,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,92.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,68,50,,551.6,Percent of Total Billed Charges,50% of Total Billed Charges,85.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,92.48,
IFE PARAPROTEIN,360823,CDM,300,RC,86334,HCPCS,Outpatient,,,71,49.7,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,48.28,
IGF BINDING PROTEIN III,360824,CDM,300,RC,82397,HCPCS,Outpatient,,,126,88.2,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,85.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,63,50,,2487.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,85.68,
"IGG SUBCLASSES 1,2,3,4 (EACH)",360825,CDM,300,RC,82787,HCPCS,Outpatient,,,11,7.7,,5.45,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,7.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,5.5,50,,753.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,16.04,
ISOHEMAGGLUTININ TEST,360827,CDM,300,RC,86886,HCPCS,Outpatient,,,95,66.5,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,47.5,50,,2487.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.36,208.54,
HIV-1 WESTERN BLOT,360830,CDM,300,RC,86689,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,642.4,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
IMMUNE CELL FUNCTION,360835,CDM,300,RC,86352,HCPCS,Outpatient,,,559,391.3,,92.38,100,,,fee schedule,100% Aetna Market fee schedule,380.12,68,,304.1,Percent of Total Billed Charges,68% of Total Billed Charges,380.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,279.5,50,,1802,Percent of Total Billed Charges,50% of Total Billed Charges,271.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,380.12,
HIV-1 ULTRASENSITIVE RNA QUANT,360836,CDM,300,RC,87536,HCPCS,Outpatient,,,269,188.3,,57.87,100,,,fee schedule,100% Aetna Market fee schedule,182.92,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,182.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,134.5,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,170.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,182.92,
HIV PHENOTYPE,360838,CDM,300,RC,87900,HCPCS,Outpatient,,,1513,1059.1,,88.64,100,,,fee schedule,100% Aetna Market fee schedule,1028.84,68,,823.07,Percent of Total Billed Charges,68% of Total Billed Charges,1028.84,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,756.5,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,260.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,1028.84,
HIV GENOTYPE,360839,CDM,300,RC,87901,HCPCS,Outpatient,,,811,567.7,,175.07,100,,,fee schedule,100% Aetna Market fee schedule,551.48,68,,441.18,Percent of Total Billed Charges,68% of Total Billed Charges,551.48,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,405.5,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,514.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,347.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,551.48,
IMMUNOELECTROPHORESIS,360840,CDM,300,RC,86320,HCPCS,Outpatient,,,71,49.7,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,611.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,59.84,
IMMUNOELECTROPHORESIS(OTHER FL,360843,CDM,300,RC,86325,HCPCS,Outpatient,,,71,49.7,,12.24,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,48.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35.5,50,,1105.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.13,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.13,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,48.28,
INHIBIN A,360844,CDM,300,RC,86336,HCPCS,Outpatient,,,50,35,,10.6,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,628.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.59,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,34,
INSULIN ANTIBODIES,360845,CDM,300,RC,86337,HCPCS,Outpatient,,,68,47.6,,14.56,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,46.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,34,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,42.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,46.24,
INHIBIN B,360846,CDM,300,RC,83520,HCPCS,Outpatient,,,168,117.6,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,114.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,84,50,,767.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,114.24,
INSULIN GROWTH FACTOR,360847,CDM,300,RC,84305,HCPCS,Outpatient,,,68,47.6,,14.46,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,46.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,34,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,42.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,46.24,
LUPUS ERYTHEMATOSUS,360850,CDM,300,RC,86403,HCPCS,Outpatient,,,32,22.4,,7.85,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,23.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,23.08,
LUPUS ANTICOAGULANT,360852,CDM,300,RC,85613,HCPCS,Outpatient,,,30,21,,6.51,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,505.2,Percent of Total Billed Charges,50% of Total Billed Charges,19.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,20.4,
LYME DISEASE IGM ELISA,360855,CDM,300,RC,86618,HCPCS,Outpatient,,,54,37.8,,11.58,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,762.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,36.72,
LYME DISEASE IGG ELISA,360860,CDM,300,RC,86618,HCPCS,Outpatient,,,72,50.4,,11.58,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,1724.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,48.96,
LYME DISEASE IGM WSTBLT,360865,CDM,300,RC,86617,HCPCS,Outpatient,,,49,34.3,,10.53,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,137.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,731.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,33.32,
LYME DISEASE IGG WSTBLT,360870,CDM,300,RC,86617,HCPCS,Outpatient,,,72,50.4,,10.53,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,3866.4,Percent of Total Billed Charges,50% of Total Billed Charges,30.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,48.96,
LYME DISEASE SEROLOGY,360875,CDM,300,RC,86618,HCPCS,Outpatient,,,54,37.8,,11.58,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,36.72,
MICROALBUMIN,360890,CDM,300,RC,82043,HCPCS,Outpatient,,,19,13.3,,3.93,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,9.5,50,,977.6,Percent of Total Billed Charges,50% of Total Billed Charges,11.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,12.92,
COXSACKIE A9 VIRUS ANTIBODIES,360891,CDM,300,RC,86658,HCPCS,Outpatient,,,56,39.2,,8.86,100,,,fee schedule,100% Aetna Market fee schedule,38.08,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,38.08,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,28,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,38.08,
EVEROLIMUS BY TANDEM MASS SPEC,360892,CDM,300,RC,80169,HCPCS,Outpatient,,,56,39.2,,9.34,100,,,fee schedule,100% Aetna Market fee schedule,38.08,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,38.08,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,28,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,27.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,38.08,
MONO TEST-SCREEN,360900,CDM,300,RC,86308,HCPCS,Outpatient,,,17,11.9,,3.52,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,3384.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,11.56,
NEUROMYELITIS OPTICA AUTO AB I,360925,CDM,300,RC,86255,HCPCS,Outpatient,,,693,485.1,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,471.24,68,,376.99,Percent of Total Billed Charges,68% of Total Billed Charges,471.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,346.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,471.24,
MUMPS VIRUS BY PCR,360930,CDM,300,RC,87798,HCPCS,Outpatient,,,492,344.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,334.56,68,,267.65,Percent of Total Billed Charges,68% of Total Billed Charges,334.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,246,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,334.56,
MUMPS IGG/IGM,360940,CDM,300,RC,86735,HCPCS,Outpatient,,,68,47.6,,8.87,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,46.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,34,50,,3416.8,Percent of Total Billed Charges,50% of Total Billed Charges,26.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,46.24,
MONO TITER,360950,CDM,300,RC,86406,HCPCS,Outpatient,,,33,23.1,,7.24,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,3416.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,22.44,
MYCOPLASMA IGG/IGM,360960,CDM,300,RC,86738,HCPCS,Outpatient,,,42,29.4,,9,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,26.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,28.56,
MYELIN ASSOC GLYCOPROTEIN IGM,360965,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2518.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
NEURONAL NUCLEAR (HU) AUTO AB,360970,CDM,300,RC,86256,HCPCS,Outpatient,,,39,27.3,,8.19,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,2518.4,Percent of Total Billed Charges,50% of Total Billed Charges,24.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,26.52,
PARVOVIRUS B19 IGG,360972,CDM,300,RC,86747,HCPCS,Outpatient,,,114,79.8,,10.22,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,30.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,77.52,
PARVOVIRUS B19 IGM,360973,CDM,300,RC,86747,HCPCS,Outpatient,,,114,79.8,,10.22,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,1270.8,Percent of Total Billed Charges,50% of Total Billed Charges,30.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,77.52,
"PROTEIN ELECTROPHORESIS, URINE",360976,CDM,300,RC,84166,HCPCS,Outpatient,,,57,39.9,,12.12,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,1802,Percent of Total Billed Charges,50% of Total Billed Charges,35.65,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.83,100,,,Fee Schedule,100% of CMS OPPS Rate,17.83,38.76,
PTH-MID MOLECULE,360980,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,628.8,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
PTH-RELATED PEPTIDE,360990,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,488,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
RAPID PLASMA REAGIN,361000,CDM,300,RC,86592,HCPCS,Outpatient,,,14,9.8,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,397.6,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,9.52,
QUANTIFERON TB GOLD,361025,CDM,300,RC,86480,HCPCS,Outpatient,,,196,137.2,,42.15,100,,,fee schedule,100% Aetna Market fee schedule,133.28,68,,106.62,Percent of Total Billed Charges,68% of Total Billed Charges,133.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,98,50,,1298,Percent of Total Billed Charges,50% of Total Billed Charges,123.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,133.28,
"RHEUMATOID FACTOR, QUAL",361050,CDM,300,RC,86430,HCPCS,Outpatient,,,18,12.6,,4.18,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,628.8,Percent of Total Billed Charges,50% of Total Billed Charges,12.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,12.28,
RHEUMATOID FACTOR QUANT,361051,CDM,300,RC,86431,HCPCS,Outpatient,,,18,12.6,,3.86,100,,,fee schedule,100% Aetna Market fee schedule,12.24,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,12.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,9,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,11.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,12.24,
ROCKY MOUNTAIN SPOTTED FVR IGM,361075,CDM,300,RC,86757,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
ROTAVIRUS-EIA,361080,CDM,300,RC,87425,HCPCS,Outpatient,,,38,26.6,,8.15,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,1478.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,25.84,
ROCKY MOUNTAIN SPOTTED FVR IGG,361090,CDM,300,RC,86757,HCPCS,Outpatient,,,61,42.7,,13.16,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,1274.4,Percent of Total Billed Charges,50% of Total Billed Charges,38.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,41.48,
RPR TITER,361129,CDM,300,RC,86593,HCPCS,Outpatient,,,15,10.5,,2.99,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,8.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,10.2,
RSV-RESP SYNCYTIAL V,361140,CDM,300,RC,87807,HCPCS,Outpatient,,,38,26.6,,8.91,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,26.2,
RUBELLA AB-IGG,361150,CDM,300,RC,86762,HCPCS,Outpatient,,,46,32.2,,9.79,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,613.63,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,28.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,31.28,
RUBEOLA AB-IGG,361170,CDM,300,RC,86765,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
RUBEOLA AB-IGM,361175,CDM,300,RC,86765,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
SJORGRENS SSA SSB,361190,CDM,300,RC,86235,HCPCS,Outpatient,,,57,39.9,,12.19,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,2189.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,38.76,
SULFOGLUCURONYL PARAGLOBOSIDE,361198,CDM,300,RC,83520,HCPCS,Outpatient,,,41,28.7,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,2414.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
VDRL-SPINAL FLUID,361200,CDM,300,RC,86593,HCPCS,Outpatient,,,15,10.5,,2.99,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,10.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,7.5,50,,457.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,10.2,
THIOPURINE METHYLTRANSFERASE (,361225,CDM,300,RC,82657,HCPCS,Outpatient,,,726,508.2,,15.08,100,,,fee schedule,100% Aetna Market fee schedule,493.68,68,,394.94,Percent of Total Billed Charges,68% of Total Billed Charges,493.68,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,363,50,,139.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,493.68,
TETANUS ANTIBODY TEST,361245,CDM,300,RC,86317,HCPCS,Outpatient,,,77,53.9,,10.19,100,,,fee schedule,100% Aetna Market fee schedule,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,52.36,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,38.5,50,,2216.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,52.36,
THYROID ANTIBODY,361250,CDM,300,RC,86376,HCPCS,Outpatient,,,47,32.9,,9.89,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,121.6,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,3696.8,Percent of Total Billed Charges,50% of Total Billed Charges,29.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,31.96,
THYROID PEROXIDASE(TPO) AB,361252,CDM,300,RC,86376,HCPCS,Outpatient,,,47,32.9,,9.89,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,3691.6,Percent of Total Billed Charges,50% of Total Billed Charges,29.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,31.96,
THYROGLOBULIN TUMOR MARKER,361253,CDM,300,RC,86800,HCPCS,Outpatient,,,34,23.8,,10.82,100,,,fee schedule,100% Aetna Market fee schedule,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,23.12,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,17,50,,542,Percent of Total Billed Charges,50% of Total Billed Charges,31.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,31.82,
THYROTROPIN RELEASING HORMONE,361254,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,434,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
THYROTROPIN RECEPTOR AB,361255,CDM,300,RC,83519,HCPCS,Outpatient,,,43,30.1,,12.51,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,179.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.4,100,,,Fee Schedule,100% of CMS OPPS Rate,18.4,36.79,
TISSUE TRANSGLUTAMINASE IGA,361257,CDM,300,RC,83520,HCPCS,Outpatient,,,37,25.9,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,141.6,Percent of Total Billed Charges,50% of Total Billed Charges,34.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,34.54,
TULAREMIA AB,361258,CDM,300,RC,86000,HCPCS,Outpatient,,,14,9.8,,4.75,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,9.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,7,50,,270,Percent of Total Billed Charges,50% of Total Billed Charges,13.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,13.96,
WEST NILE VIRUS ANTIGEN BY PCR,361260,CDM,300,RC,87798,HCPCS,Outpatient,,,112,78.4,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,976.45,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,246.8,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,76.16,
WEST NILE VIRUS ANTIBODY IGG,361261,CDM,300,RC,86790,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,670,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
WEST NILE VIRUS ANTIBODY IGM,361262,CDM,300,RC,86790,HCPCS,Outpatient,,,41,28.7,,8.76,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,142,Percent of Total Billed Charges,50% of Total Billed Charges,25.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,27.88,
17-D HYDROXYPROGESTERONE,361275,CDM,300,RC,83498,HCPCS,Outpatient,,,86,60.2,,18.48,100,,,fee schedule,100% Aetna Market fee schedule,58.48,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,58.48,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,43,50,,222,Percent of Total Billed Charges,50% of Total Billed Charges,54.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,58.48,
TYPE & CROSSMATCH-AHG,361950,CDM,300,RC,86922,HCPCS,Outpatient,,,112,78.4,,24.39,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,1166.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,56,208.54,
TYPE & CROSSMATCH-INC,361955,CDM,300,RC,86921,HCPCS,Outpatient,,,112,78.4,,20.59,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,193.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,56,208.54,
TYPE & CROSSMATCH-IS,361960,CDM,300,RC,86920,HCPCS,Outpatient,,,112,78.4,,22.83,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,76.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,56,50,,124,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,56,208.54,
QUANTITATIVE EACH SPECIMEN,370495,CDM,300,RC,83789,HCPCS,Outpatient,,,58,40.6,,16.39,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,828.8,Percent of Total Billed Charges,50% of Total Billed Charges,48.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,48.22,
MEPROBAMATE,370500,CDM,300,RC,83805,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,635.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
SINGLE SPECIMEN,370505,CDM,300,RC,80301,HCPCS,Outpatient,,,58,40.6,,,,,,Other,Not Seperately Reimbusable,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,50.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
CHAIN OF CUST UDS/NON CORPORAT,370510,CDM,300,RC,,,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,311.6,Percent of Total Billed Charges,50% of Total Billed Charges,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,75,,39,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,39,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13,48.75,
UDS C.O.C. COLLECTION ONLY/NO,370515,CDM,300,RC,,,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.72,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,14.5,50,,333.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.85,65,,15.08,Percent of Total Billed Charges,65% of Total Billed Charges,21.75,75,,17.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,17.4,60,,13.92,Percent of Total Billed Charges,60% of Total Billed Charges,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.92,20.4,,4.74,Percent of Total Billed Charges,20.4% of Total Billed Charges,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.8,20,,4.64,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.8,21.75,
UDS COLLECTION - LPN,370517,CDM,300,RC,,,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1111.42,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,813.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.95,65,,22.36,Percent of Total Billed Charges,65% of Total Billed Charges,32.25,75,,25.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,25.8,60,,20.64,Percent of Total Billed Charges,60% of Total Billed Charges,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.77,20.4,,7.02,Percent of Total Billed Charges,20.4% of Total Billed Charges,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.6,20,,6.88,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8.6,32.25,
CORPORATE C.O.C. UDS,370520,CDM,300,RC,,,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,960,Percent of Total Billed Charges,50% of Total Billed Charges,42.25,65,,33.8,Percent of Total Billed Charges,65% of Total Billed Charges,48.75,75,,39,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,39,60,,31.2,Percent of Total Billed Charges,60% of Total Billed Charges,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13.26,20.4,,10.61,Percent of Total Billed Charges,20.4% of Total Billed Charges,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,20,,10.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13,48.75,
CORPORATE C.O.C. UDS AND ETOH,370525,CDM,300,RC,,,Outpatient,,,90,63,,,,,,Other,Not Seperately Reimbusable,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,198.8,Percent of Total Billed Charges,50% of Total Billed Charges,58.5,65,,46.8,Percent of Total Billed Charges,65% of Total Billed Charges,67.5,75,,54,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,54,60,,43.2,Percent of Total Billed Charges,60% of Total Billed Charges,18.36,20.4,,14.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18.36,20.4,,14.69,Percent of Total Billed Charges,20.4% of Total Billed Charges,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,20,,14.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,18,67.5,
CORPORATE C.O.C. ALCOHOL,370530,CDM,300,RC,,,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,718.4,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,18.75,
CORPORATE HAIR DRUG TEST COLLE,370535,CDM,300,RC,,,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,12.5,50,,1685.6,Percent of Total Billed Charges,50% of Total Billed Charges,16.25,65,,13,Percent of Total Billed Charges,65% of Total Billed Charges,18.75,75,,15,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,15,60,,12,Percent of Total Billed Charges,60% of Total Billed Charges,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5.1,20.4,,4.08,Percent of Total Billed Charges,20.4% of Total Billed Charges,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,20,,4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,5,18.75,
CORPORATE HAIR DRUG TEST COLL,370540,CDM,300,RC,,,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,108.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,79.5,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,103.35,65,,82.68,Percent of Total Billed Charges,65% of Total Billed Charges,119.25,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,95.4,60,,76.32,Percent of Total Billed Charges,60% of Total Billed Charges,32.44,20.4,,25.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,32.44,20.4,,25.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.8,20,,25.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,31.8,119.25,
CORPORATE UDS CONFIRMATION,370545,CDM,300,RC,,,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,208,Percent of Total Billed Charges,50% of Total Billed Charges,24.05,65,,19.24,Percent of Total Billed Charges,65% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.2,60,,17.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.4,27.75,
DRUG CONFIRMATION BY GC/MS,370553,CDM,300,RC,82542,HCPCS,Outpatient,,,58,40.6,,16.38,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,48.18,
D.O.T. DRUG SCREEN PERFORMED A,370555,CDM,300,RC,,,Outpatient,,,123,86.1,,,,,,Other,Not Seperately Reimbusable,83.64,68,,66.91,Percent of Total Billed Charges,68% of Total Billed Charges,83.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,61.5,50,,7675.2,Percent of Total Billed Charges,50% of Total Billed Charges,79.95,65,,63.96,Percent of Total Billed Charges,65% of Total Billed Charges,92.25,75,,73.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.6,20,,19.68,Percent of Total Billed Charges,20% of Total Billed Charges,73.8,60,,59.04,Percent of Total Billed Charges,60% of Total Billed Charges,25.09,20.4,,20.07,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25.09,20.4,,20.07,Percent of Total Billed Charges,20.4% of Total Billed Charges,24.6,20,,19.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.6,20,,19.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24.6,92.25,
D.O.T. DRUG SCREEN COLLECTION,370565,CDM,300,RC,,,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,347.2,Percent of Total Billed Charges,50% of Total Billed Charges,25.35,65,,20.28,Percent of Total Billed Charges,65% of Total Billed Charges,29.25,75,,23.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,23.4,60,,18.72,Percent of Total Billed Charges,60% of Total Billed Charges,7.96,20.4,,6.37,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.96,20.4,,6.37,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.8,20,,6.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.8,29.25,
HAIR DRUG SCREEN,370566,CDM,300,RC,80307,HCPCS,Outpatient,,,69,48.3,,42.26,100,,,fee schedule,100% Aetna Market fee schedule,46.92,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,46.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,34.5,50,,7675.2,Percent of Total Billed Charges,50% of Total Billed Charges,124.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,34.5,124.28,
ECSTACY (MDMA),370567,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,9320.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
LEVETIRACETAM,370568,CDM,300,RC,82542,HCPCS,Outpatient,,,58,40.6,,16.38,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,94.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,48.18,
ECSTACY (MDMA) CONFIRMATION,370569,CDM,300,RC,80359,HCPCS,Outpatient,,,83,58.1,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,718.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,56.44,
MECONIUM DRUG SCREEN 4006,370570,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,134,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
"D/L METHAMPHETAMINE, TOXASSURE",370571,CDM,300,RC,80324,HCPCS,Outpatient,,,162,113.4,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,110.16,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,110.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,81,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81,110.16,
MECONIUM DRUG SCREEN 4007,370575,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,2189.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
MECONIUM DRUG SCREEN 4008,370580,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,2189.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
MECONIUM DRUG SCREEN 4011,370585,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,1875.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
MECONIUM DRUG SCREEN 4001,370590,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,1166,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
MECONIUM DRUG SCREEN 4002,370600,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,1120,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
MECONIUM DRUG SCREEN 4003,370610,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,1658,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
MECONIUM DRUG SCREEN 4012,370615,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,972.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
MECONIUM DRUG SCREEN,370620,CDM,300,RC,80100,HCPCS,Outpatient,,,42,29.4,,,,,,Other,Not Seperately Reimbusable,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,3215.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,28.56,
MECONIUM DRUG SCREEN 4005,370625,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,3768,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
MECONIUM DRUG SCREEN 4009,370630,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,1270.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
MECONIUM DRUG SCREEN 4010,370635,CDM,300,RC,80100,HCPCS,Outpatient,,,46,32.2,,,,,,Other,Not Seperately Reimbusable,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,31.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23,50,,3899.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,31.28,
METHADONE,370640,CDM,300,RC,G0431,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,4000,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
METHADONE CONFIRMATION,370642,CDM,300,RC,80358,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,3470.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
METHAMPHETAMINE(MAMP) URINE SC,370643,CDM,300,RC,80305,HCPCS,Outpatient,,,167,116.9,,8.57,100,,,fee schedule,100% Aetna Market fee schedule,113.56,68,,90.85,Percent of Total Billed Charges,68% of Total Billed Charges,113.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,83.5,50,,1990.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,113.56,
NICOTINE SERUM,370645,CDM,300,RC,80323,HCPCS,Outpatient,,,90,63,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,1270.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,61.2,
OXYCODONE(OXY) URINE SCREEN,370646,CDM,300,RC,80305,HCPCS,Outpatient,,,224,156.8,,8.57,100,,,fee schedule,100% Aetna Market fee schedule,152.32,68,,121.86,Percent of Total Billed Charges,68% of Total Billed Charges,152.32,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,112,50,,2994,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,152.32,
OXYCODONE CONFIRMATION,370647,CDM,300,RC,80365,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,4000,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
PROPOXYPHENE,370648,CDM,300,RC,80301,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,2194.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
PROPOXYPHENE CONFIRMATION,370649,CDM,300,RC,80367,HCPCS,Outpatient,,,58,40.6,,0.01,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,2099.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,39.44,
HCG TITER,370650,CDM,300,RC,84702,HCPCS,Outpatient,,,22,15.4,,10.23,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,14.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,11,50,,481.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11,30.1,
DRUG SCREEN,370660,CDM,300,RC,80305,HCPCS,Outpatient,,,194,135.8,,8.57,100,,,fee schedule,100% Aetna Market fee schedule,131.92,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,131.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,97,50,,1382,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,131.92,
LVT -ACETOMINOPHEN 1,370661,CDM,300,RC,G6039,HCPCS,Outpatient,,,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,1462.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,51.68,
LVT -ACETOMINOPHEN2/59,370662,CDM,300,RC,G6039,HCPCS,Outpatient,,,76,53.2,,,,,,Other,Not Seperately Reimbusable,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,508.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,51.68,
LVT -ALCOHOL1,370663,CDM,300,RC,G0483,HCPCS,Outpatient,,,41,28.7,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,648.4,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,20.5,493.84,
LVT -ALCOHOL2/59,370664,CDM,300,RC,G0483,HCPCS,Outpatient,,,41,28.7,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,508.4,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,20.5,493.84,
LVT -ALKALOIDS1 URINE QU,370665,CDM,300,RC,G0483,HCPCS,Outpatient,,,80,56,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,2512,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,40,493.84,
LVT -AMITRIPTYLINE,370666,CDM,300,RC,G0483,HCPCS,Outpatient,,,67,46.9,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,45.56,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,45.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,33.5,50,,2512,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.5,493.84,
LVT -AMITRIPTYLINE2/59,370667,CDM,300,RC,G6030,HCPCS,Outpatient,,,67,46.9,,,,,,Other,Not Seperately Reimbusable,45.56,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,45.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,33.5,50,,1149.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.5,45.56,
LVT -AMPHETAMINE OR METHAMPHET,370668,CDM,300,RC,G0483,HCPCS,Outpatient,,,117,81.9,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,79.56,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,58.5,50,,2314,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,58.5,493.84,
LVT -AMPHETAMINE OR MEATHM2/59,370669,CDM,300,RC,G6042,HCPCS,Outpatient,,,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,40.12,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29.5,50,,2599.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,40.12,
LVT -BARBITURATES NES,370670,CDM,300,RC,G0483,HCPCS,Outpatient,,,86,60.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,58.48,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,58.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,43,50,,270.4,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,43,493.84,
LVT -BARBITURATES2 /59 NES,370671,CDM,300,RC,G6043,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,1996,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,29.24,
LVT -BENZODIAZEPINES,370672,CDM,300,RC,G6031,HCPCS,Outpatient,,,139,97.3,,,,,,Other,Not Seperately Reimbusable,94.52,68,,75.62,Percent of Total Billed Charges,68% of Total Billed Charges,94.52,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,69.5,50,,1105.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.5,94.52,
LVT -BENZODIAZEPINES2/59,370673,CDM,300,RC,G6031,HCPCS,Outpatient,,,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,47.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,35,50,,4000,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,47.6,
LVT -COCAINE /METABOLITE,370674,CDM,300,RC,G0483,HCPCS,Outpatient,,,57,39.9,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,2314,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,493.84,
LVT -COCAINE/METABOLITE 2/59,370675,CDM,300,RC,G6044,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,847.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,38.76,
DRUG SCREEN,370676,CDM,300,RC,80307,HCPCS,Outpatient,,,194,135.8,,42.26,100,,,fee schedule,100% Aetna Market fee schedule,131.92,68,,105.54,Percent of Total Billed Charges,68% of Total Billed Charges,131.92,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,97,50,,285.2,Percent of Total Billed Charges,50% of Total Billed Charges,124.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,131.92,
LVT -DESIPRAMINE,370677,CDM,300,RC,G0483,HCPCS,Outpatient,,,65,45.5,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,920,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,32.5,493.84,
LVT -DESIPRAMINE2/59,370678,CDM,300,RC,G6032,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,44.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,32.5,50,,1632.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,44.2,
LVT -DRUG SCREEN OTHER 2/59,370680,CDM,300,RC,G0434,HCPCS,Outpatient,,,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,150,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,22.44,
LVT -DIHYDROCODEINONE,370681,CDM,300,RC,G0483,HCPCS,Outpatient,,,76,53.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,51.68,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,38,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,38,493.84,
LVT -DIHYDROMORPHINONE,370682,CDM,300,RC,G0483,HCPCS,Outpatient,,,74,51.8,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,50.32,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,37,50,,1484,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,37,493.84,
LVT -DIHDROCODEINE,370683,CDM,300,RC,G0483,HCPCS,Outpatient,,,97,67.9,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,65.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,48.5,50,,2066.8,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,48.5,493.84,
LVT -DIMETHADIONE,370684,CDM,300,RC,G0483,HCPCS,Outpatient,,,52,36.4,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,35.36,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,35.36,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,26,50,,660.4,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26,493.84,
LVT -DOXEPIN,370685,CDM,300,RC,G0483,HCPCS,Outpatient,,,58,40.6,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,545.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29,493.84,
LVT -DOXEPIN2/59,370686,CDM,300,RC,G0483,HCPCS,Outpatient,,,58,40.6,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,2276,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29,493.84,
DRUG TEST DEF 15-21 CLASSES,370687,CDM,300,RC,G0482,HCPCS,Outpatient,,,596,417.2,,135.14,100,,,fee schedule,100% Aetna Market fee schedule,405.28,68,,324.22,Percent of Total Billed Charges,68% of Total Billed Charges,405.28,68,,1091.97,Percent of Total Billed Charges,68% of Total Billed Charges,298,50,,519.2,Percent of Total Billed Charges,50% of Total Billed Charges,397.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,198.74,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,405.28,
LVT -DRUG CONF2/59,370688,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,2562.11,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,519.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF3 W/59,370689,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,267.52,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,1200,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF4 W/59,370690,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,316.16,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,866.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF5 W/59,370691,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,48.64,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,2066.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF6 W/59,370692,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,11666.3,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,2066.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF7 W/59,370693,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,527.74,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,1380.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF8 W/59,370694,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,11666.3,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,866.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF9 W/59,370695,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,14167.62,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,4000,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF10 W/59,370696,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,143.49,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,274,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -DRUG CONF11 W/59,370697,CDM,300,RC,G6058,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,19.04,68,,1091.97,Percent of Total Billed Charges,68% of Total Billed Charges,14,50,,2276,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,19.04,
LVT -EPIANDROSTERONE,370698,CDM,300,RC,G0483,HCPCS,Outpatient,,,81,56.7,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,55.08,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,40.5,50,,2564,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,493.84,
LVT -ETHCHLORVYNOL,370699,CDM,300,RC,G0483,HCPCS,Outpatient,,,60,42,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,2564,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,30,493.84,
5 HIAA(5HYDROX-CETIC,370700,CDM,300,RC,83497,HCPCS,Outpatient,,,41,28.7,,8.77,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,1380.8,Percent of Total Billed Charges,50% of Total Billed Charges,25.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,27.88,
LVT -FLURAZEPAM,370701,CDM,300,RC,G0483,HCPCS,Outpatient,,,75,52.5,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,1380.8,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,37.5,493.84,
LVT -GOLD,370702,CDM,300,RC,G0483,HCPCS,Outpatient,,,61,42.7,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,2564,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,493.84,
LVT -GOLD2 W/59,370703,CDM,300,RC,G0483,HCPCS,Outpatient,,,61,42.7,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,41.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,30.5,50,,866.4,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,493.84,
LVT -IMIPRAMINE,370704,CDM,300,RC,G0483,HCPCS,Outpatient,,,32,22.4,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,367.6,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,16,493.84,
LVT -IMIPRAMINE2 W/59,370705,CDM,300,RC,G6036,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,243.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,21.76,
LVT -MEPROBAMATE,370706,CDM,300,RC,G0483,HCPCS,Outpatient,,,66,46.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,3708,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33,493.84,
LVT -MEPROBAMATE2 W/59,370707,CDM,300,RC,G6052,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,44.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,33,50,,500.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,44.88,
LVT -METHADONE,370708,CDM,300,RC,G0483,HCPCS,Outpatient,,,57,39.9,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,38.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,28.5,50,,2564,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,493.84,
LVT -METHADONE2 W/59,370709,CDM,300,RC,G6053,HCPCS,Outpatient,,,29,20.3,,,,,,Other,Not Seperately Reimbusable,19.72,68,,15.78,Percent of Total Billed Charges,68% of Total Billed Charges,19.72,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,14.5,50,,545.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.5,19.72,
LVT -METHSUXIMIDE,370710,CDM,300,RC,G0483,HCPCS,Outpatient,,,56,39.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,38.08,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,38.08,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,28,50,,2564,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,28,493.84,
LVT -NICOTINE,370711,CDM,300,RC,G0483,HCPCS,Outpatient,,,45,31.5,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,30.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,22.5,50,,305.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,493.84,
LVT -NICOTINE2 W/59,370712,CDM,300,RC,G6055,HCPCS,Outpatient,,,45,31.5,,,,,,Other,Not Seperately Reimbusable,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,30.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,22.5,50,,2564,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.5,30.6,
LVT -NORTRIPTYLINE,370713,CDM,300,RC,G6037,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,2564,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,34.68,
LVT -NORTRIPTYLINE2 W/59,370714,CDM,300,RC,G6037,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,2066.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,34.68,
LVT -OPIATES DRUG METABOLITES,370715,CDM,300,RC,G0483,HCPCS,Outpatient,,,292,204.4,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,198.56,68,,158.85,Percent of Total Billed Charges,68% of Total Billed Charges,198.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,146,50,,443.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,146,493.84,
LVT -OPIATES METABOLITE2 W/59,370716,CDM,300,RC,G0480,HCPCS,Outpatient,,,73,51.1,,77.81,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,49.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,36.5,50,,548,Percent of Total Billed Charges,50% of Total Billed Charges,228.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.5,228.86,
LVT -OPIATES METABOLITES3 W/59,370717,CDM,300,RC,G0480,HCPCS,Outpatient,,,73,51.1,,77.81,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,49.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,36.5,50,,549.2,Percent of Total Billed Charges,50% of Total Billed Charges,228.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.5,228.86,
LVT -PHENOTHIAZINE,370718,CDM,300,RC,G0483,HCPCS,Outpatient,,,26,18.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,565.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,13,493.84,
LVT -PHENOTHIAZINE2 W/59,370719,CDM,300,RC,G0483,HCPCS,Outpatient,,,26,18.2,,167.91,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,731.42,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,93.2,Percent of Total Billed Charges,50% of Total Billed Charges,493.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,13,493.84,
LVT -OPIATES METABOLITE4 W/59,370720,CDM,300,RC,G0480,HCPCS,Outpatient,,,73,51.1,,77.81,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,49.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,36.5,50,,108,Percent of Total Billed Charges,50% of Total Billed Charges,228.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.5,228.86,
17 HYD. CORTICO STRD,370750,CDM,300,RC,83491,HCPCS,Outpatient,,,55,38.5,,12.17,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,35.79,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.9,100,,,Fee Schedule,100% of CMS OPPS Rate,17.9,37.4,
17 KETO GENTIC STRD.,370800,CDM,300,RC,83586,HCPCS,Outpatient,,,41,28.7,,8.7,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.8,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,27.88,
17-OH PROGESTERONE LCMS,370810,CDM,300,RC,83498,HCPCS,Outpatient,,,158,110.6,,18.48,100,,,fee schedule,100% Aetna Market fee schedule,107.44,68,,85.95,Percent of Total Billed Charges,68% of Total Billed Charges,107.44,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,79,50,,40.4,Percent of Total Billed Charges,50% of Total Billed Charges,54.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,107.44,
METANEPHRINE,370900,CDM,300,RC,83835,HCPCS,Outpatient,,,54,37.8,,11.52,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,36.72,
METANEPHRINES  PLASMA,370920,CDM,300,RC,83835,HCPCS,Outpatient,,,54,37.8,,11.52,100,,,fee schedule,100% Aetna Market fee schedule,36.72,68,,29.38,Percent of Total Billed Charges,68% of Total Billed Charges,36.72,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,27,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,36.72,
METHYLMALONIC ACID,370925,CDM,300,RC,82131,HCPCS,Outpatient,,,53,37.1,,15.63,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,36.04,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,26.5,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,45.96,
PORPHYRINS (QUANT),370950,CDM,300,RC,84120,HCPCS,Outpatient,,,47,32.9,,10,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,31.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,23.5,50,,34.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,31.96,
URINE PREGNANCY TEST,371000,CDM,300,RC,81025,HCPCS,Outpatient,,,20,14,,5.85,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,17.22,
PROTEIN (24 HR URINE),371050,CDM,300,RC,84156,HCPCS,Outpatient,,,13,9.1,,2.5,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,7.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,8.84,
STONE ANALYSIS-CHEMICAL,371100,CDM,300,RC,82360,HCPCS,Outpatient,,,41,28.7,,8.75,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,27.88,
URINALYSIS (COMPLETE),371200,CDM,300,RC,81001,HCPCS,Outpatient,,,90,63,,2.16,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,245.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,61.2,
URINALYSIS (NO MICRO),371225,CDM,300,RC,81003,HCPCS,Outpatient,,,7,4.9,,1.53,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,4.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,3.5,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,4.76,
KIDNEY STONE URINE TEST COMB W,371226,CDM,300,RC,81003,HCPCS,Outpatient,,,130,91,,1.53,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,88.4,
URINALYSIS (MICRO ONLY),371250,CDM,300,RC,81015,HCPCS,Outpatient,,,9,6.3,,2.07,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,4.5,50,,90.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,6.12,
UROBILINOGEN (QUAL. URINE),371300,CDM,300,RC,84578,HCPCS,Outpatient,,,10,7,,3.04,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,6.8,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,5,50,,101.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.47,100,,,Fee Schedule,100% of CMS OPPS Rate,4.47,8.94,
GIARDIA IGG ANTIBODY,860703,CDM,300,RC,86674,HCPCS,Outpatient,,,26,18.2,,10.01,100,,,fee schedule,100% Aetna Market fee schedule,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,17.68,68,,1398.4,Percent of Total Billed Charges,68% of Total Billed Charges,13,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13,29.44,
TOXOCOLOGY PANEL SCREENING,893388,CDM,300,RC,80307,HCPCS,Outpatient,,,734,513.8,,42.26,100,,,fee schedule,100% Aetna Market fee schedule,499.12,68,,399.3,Percent of Total Billed Charges,68% of Total Billed Charges,499.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,367,50,,85.6,Percent of Total Billed Charges,50% of Total Billed Charges,124.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,499.12,
DRUG TEST DEF 8-14 CLASSES,893400,CDM,300,RC,G0481,HCPCS,Outpatient,,,470,329,,106.48,100,,,fee schedule,100% Aetna Market fee schedule,319.6,68,,255.68,Percent of Total Billed Charges,68% of Total Billed Charges,319.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,235,50,,136,Percent of Total Billed Charges,50% of Total Billed Charges,313.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,156.59,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,319.6,
DRUG TEST OPTICAL OBSRVTN IN H,893410,CDM,300,RC,80305,HCPCS,Outpatient,,,734,513.8,,8.57,100,,,fee schedule,100% Aetna Market fee schedule,499.12,68,,399.3,Percent of Total Billed Charges,68% of Total Billed Charges,499.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,367,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,25.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,499.12,
ROUTINE VENIPUNCTURE,3641500,CDM,300,RC,36415,HCPCS,Outpatient,,,20,14,,2.04,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,17.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.83,17.66,
LAB/URINALYSIS AUTOMATED W/O M,8100300,CDM,300,RC,81003,HCPCS,Outpatient,,,45,31.5,,1.53,100,,,fee schedule,100% Aetna Market fee schedule,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,30.6,68,,24.48,Percent of Total Billed Charges,68% of Total Billed Charges,22.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,4.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,30.6,
LAB/BLOOD SUGAR,8296200,CDM,300,RC,82962,HCPCS,Outpatient,,,13,9.1,,2.23,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,6.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,8.84,
LAB/WET PREP,8721000,CDM,300,RC,87210,HCPCS,Outpatient,,,16,11.2,,3.96,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,8,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,11.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,11.64,
LAB/COVID-19 ANTIGEN,8763500,CDM,300,RC,87635,HCPCS,Outpatient,,,153,107.1,,51.31,100,,,fee schedule,100% Aetna Market fee schedule,104.04,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,104.04,68,,83.23,Percent of Total Billed Charges,68% of Total Billed Charges,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,102.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,69.27,135,,,Fee Schedule,135% of CMS OPPS Rate,37.68,102,,,Fee Schedule,102% MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS rate,37.68,102,,,Fee Schedule,102% of MO Medicaid rate,36.94,100,,,Fee Schedule,100% of MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,36.94,104.04,
LAB/INFLUENZA SWAB,8780400,CDM,300,RC,87804,HCPCS,Outpatient,,,75,52.5,,11.25,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,33.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,51,
LAB/RSV SWAB,8780700,CDM,300,RC,87807,HCPCS,Outpatient,,,155,108.5,,8.91,100,,,fee schedule,100% Aetna Market fee schedule,105.4,68,,84.32,Percent of Total Billed Charges,68% of Total Billed Charges,105.4,68,,84.32,Percent of Total Billed Charges,68% of Total Billed Charges,77.5,50,,62,Percent of Total Billed Charges,50% of Total Billed Charges,26.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,105.4,
SCREENING PAP SMEAR,8789000,CDM,300,RC,Q0091,HCPCS,Outpatient,,,115,80.5,,16.55,100,,,fee schedule,100% Aetna Market fee schedule,78.2,68,,62.56,Percent of Total Billed Charges,68% of Total Billed Charges,78.2,68,,62.56,Percent of Total Billed Charges,68% of Total Billed Charges,57.5,50,,46,Percent of Total Billed Charges,50% of Total Billed Charges,34.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.93,100,,,Fee Schedule,100% of CMS OPPS Rate,26.93,78.2,
ACETAMINOPHEN,310400,CDM,301,RC,80143,HCPCS,Outpatient,,,56,39.2,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,38.08,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,38.08,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,28,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,38.08,
SALICYLATE,314500,CDM,301,RC,80179,HCPCS,Outpatient,,,56,39.2,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,38.08,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,38.08,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,28,50,,556,Percent of Total Billed Charges,50% of Total Billed Charges,37.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,38.08,
URINALYSIS WO MICRO MANUAL,371210,CDM,301,RC,81002,HCPCS,Outpatient,,,90,63,,2.37,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,436.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,61.2,
DRUG TEST DEF 1-7 CLASSES,893420,CDM,301,RC,G0480,HCPCS,Outpatient,,,343,240.1,,77.81,100,,,fee schedule,100% Aetna Market fee schedule,233.24,68,,186.59,Percent of Total Billed Charges,68% of Total Billed Charges,233.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,171.5,50,,162.8,Percent of Total Billed Charges,50% of Total Billed Charges,228.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,233.24,
SERUM DRUG SCREEN,893503,CDM,301,RC,80307,HCPCS,Outpatient,,,186,130.2,,42.26,100,,,fee schedule,100% Aetna Market fee schedule,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,126.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,93,50,,680.8,Percent of Total Billed Charges,50% of Total Billed Charges,124.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,126.48,
MASS SPEC ANALYTE NOS QUANT,893675,CDM,301,RC,83789,HCPCS,Outpatient,,,240,168,,16.39,100,,,fee schedule,100% Aetna Market fee schedule,163.2,68,,130.56,Percent of Total Billed Charges,68% of Total Billed Charges,163.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,120,50,,112,Percent of Total Billed Charges,50% of Total Billed Charges,48.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,163.2,
FECL OCCLT COLRCTL NEOPLSM SCR,8227000,CDM,301,RC,82270,HCPCS,Outpatient,,,38,26.6,,2.98,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,19,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,25.84,
SKIN TEST TUBERCULOSIS INTRADE,8658000,CDM,302,RC,86580,HCPCS,Outpatient,,,180,126,,6.92,100,,,fee schedule,100% Aetna Market fee schedule,122.4,68,,97.92,Percent of Total Billed Charges,68% of Total Billed Charges,122.4,68,,97.92,Percent of Total Billed Charges,68% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.8,122.4,
BLOOD COUNT HEMOGLOBIN (HGB),8501800,CDM,305,RC,85018,HCPCS,Outpatient,,,49,34.3,,1.61,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,33.32,
IADNA CHLAMYDIA TRACH AMP PROB,360722,CDM,306,RC,87491,HCPCS,Outpatient,,,105,73.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,71.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,52.5,50,,1417.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,71.4,
IADNA GONNORRHOEAE AMP PROBE T,360723,CDM,306,RC,87591,HCPCS,Outpatient,,,105,73.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,71.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,52.5,50,,1875.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,71.4,
IADNA TRICHOMONAS VAG AMP PROB,360724,CDM,306,RC,87661,HCPCS,Outpatient,,,105,73.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,71.4,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,71.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,52.5,50,,844,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,71.4,
RESP VIRUS 3-5 TARGETS,360730,CDM,306,RC,87631,HCPCS,Outpatient,,,185,129.5,,96.99,100,,,fee schedule,100% Aetna Market fee schedule,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,125.8,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,92.5,50,,3768,Percent of Total Billed Charges,50% of Total Billed Charges,285.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,92.5,285.26,
RESP VIRUS 6-11 TARGETS,360731,CDM,306,RC,87632,HCPCS,Outpatient,,,283,198.1,,148.28,100,,,fee schedule,100% Aetna Market fee schedule,192.44,68,,153.95,Percent of Total Billed Charges,68% of Total Billed Charges,192.44,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,141.5,50,,3215.6,Percent of Total Billed Charges,50% of Total Billed Charges,436.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,218.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,141.5,436.12,
RESPIR IADNA 18 VIRAL&2 BACT,360732,CDM,306,RC,0115U,HCPCS,Outpatient,,,542,379.4,,187.24,100,,,fee schedule,100% Aetna Market fee schedule,368.56,68,,294.85,Percent of Total Billed Charges,68% of Total Billed Charges,368.56,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,271,50,,958.8,Percent of Total Billed Charges,50% of Total Billed Charges,550.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,275.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.35,100,,,Fee Schedule,100% of CMS OPPS Rate,271,550.7,
INFECT AGNT DETECTION COVID-19,360733,CDM,306,RC,87635,HCPCS,Outpatient,,,130,91,,51.31,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,102.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,69.27,135,,,Fee Schedule,135% of CMS OPPS Rate,37.68,102,,,Fee Schedule,102% MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS rate,37.68,102,,,Fee Schedule,102% of MO Medicaid rate,36.94,100,,,Fee Schedule,100% of MO Medicaid rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.94,100,,,Fee Schedule,100% of MO Medicaid Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,36.94,102.62,
COVID-19 NON CDC,360734,CDM,306,RC,U0002,HCPCS,Outpatient,,,130,91,,51.31,100,,,fee schedule,100% Aetna Market fee schedule,88.4,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,88.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,65,50,,972.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,51.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,102.62,
M. GENITALIUM AMP PROBE,893663,CDM,306,RC,87563,HCPCS,Outpatient,,,125,87.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,85,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,62.5,50,,74.4,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,85,
DETECT AGENT NOS DNA AMP,893664,CDM,306,RC,87798,HCPCS,Outpatient,,,125,87.5,,23.86,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,85,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,62.5,50,,88,Percent of Total Billed Charges,50% of Total Billed Charges,70.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,85,
TISSUE EXAMINATN BY KOH,8722000,CDM,306,RC,87220,HCPCS,Outpatient,,,42,29.4,,2.9,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,8.53,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,28.56,
RAPID STREP GROUP A,8788000,CDM,306,RC,87880,HCPCS,Outpatient,,,50,35,,11.24,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,33.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,34,
"URINE DRUG SCREEN, 1-10 CLASSE",893417,CDM,307,RC,80307,HCPCS,Outpatient,,,186,130.2,,42.26,100,,,fee schedule,100% Aetna Market fee schedule,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,126.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,93,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,124.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,126.48,
HUMN CHRION GONADOTRP URINE,8102500,CDM,307,RC,81025,HCPCS,Outpatient,,,50,35,,5.85,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,17.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,34,
AP TC LEVEL 1,348200,CDM,310,RC,88300,HCPCS,Outpatient,,,44,30.8,TC,2.98,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,29.92,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,22,50,,971.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.89,100,,,Fee Schedule,100% of MO Medicaid Rate,36.35,135,,,Fee Schedule,135% of CMS OPPS Rate,14.17,102,,,Fee Schedule,102% MO Medicaid rate,26.92,100,,,Fee Schedule,100% of CMS OPPS rate,14.17,102,,,Fee Schedule,102% of MO Medicaid rate,13.89,100,,,Fee Schedule,100% of MO Medicaid rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.89,100,,,Fee Schedule,100% of MO Medicaid Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,13.89,36.35,
AP TC LEVEL 2,348205,CDM,310,RC,88302,HCPCS,Outpatient,,,93,65.1,TC,4.6,100,,,fee schedule,100% Aetna Market fee schedule,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,63.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,46.5,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.26,100,,,Fee Schedule,100% of MO Medicaid Rate,36.35,135,,,Fee Schedule,135% of CMS OPPS Rate,28.83,102,,,Fee Schedule,102% MO Medicaid rate,26.92,100,,,Fee Schedule,100% of CMS OPPS rate,28.83,102,,,Fee Schedule,102% of MO Medicaid rate,28.26,100,,,Fee Schedule,100% of MO Medicaid rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.26,100,,,Fee Schedule,100% of MO Medicaid Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,63.24,
AP TC LEVEL 3,348210,CDM,310,RC,88304,HCPCS,Outpatient,,,96,67.2,TC,7.62,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,65.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,48,50,,3416.8,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.53,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,37.26,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,37.26,102,,,Fee Schedule,102% of MO Medicaid rate,36.53,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.53,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,36.53,66.16,
AP TC LEVEL 4,348215,CDM,310,RC,88305,HCPCS,Outpatient,,,131,91.7,TC,22.36,100,,,fee schedule,100% Aetna Market fee schedule,89.08,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,89.08,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,65.5,50,,1854.8,Percent of Total Billed Charges,50% of Total Billed Charges,61.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.41,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,62.64,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,62.64,102,,,Fee Schedule,102% of MO Medicaid rate,61.41,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.41,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,49,89.08,
AP TC LEVEL 5,348220,CDM,310,RC,88307,HCPCS,Outpatient,,,511,357.7,TC,55.01,100,,,fee schedule,100% Aetna Market fee schedule,347.48,68,,277.98,Percent of Total Billed Charges,68% of Total Billed Charges,347.48,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,255.5,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,358.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.74,100,,,Fee Schedule,100% of MO Medicaid Rate,438.87,135,,,Fee Schedule,135% of CMS OPPS Rate,249.63,102,,,Fee Schedule,102% MO Medicaid rate,325.09,100,,,Fee Schedule,100% of CMS OPPS rate,249.63,102,,,Fee Schedule,102% of MO Medicaid rate,244.74,100,,,Fee Schedule,100% of MO Medicaid rate,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,244.74,100,,,Fee Schedule,100% of MO Medicaid Rate,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,244.74,438.87,
AP TC LEVEL 6,348225,CDM,310,RC,88309,HCPCS,Outpatient,,,782,547.4,TC,96.66,100,,,fee schedule,100% Aetna Market fee schedule,531.76,68,,425.41,Percent of Total Billed Charges,68% of Total Billed Charges,531.76,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,391,50,,1084,Percent of Total Billed Charges,50% of Total Billed Charges,503.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.23,100,,,Fee Schedule,100% of MO Medicaid Rate,1049.89,135,,,Fee Schedule,135% of CMS OPPS Rate,375.59,102,,,Fee Schedule,102% MO Medicaid rate,777.7,100,,,Fee Schedule,100% of CMS OPPS rate,375.59,102,,,Fee Schedule,102% of MO Medicaid rate,368.23,100,,,Fee Schedule,100% of MO Medicaid rate,777.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,368.23,100,,,Fee Schedule,100% of MO Medicaid Rate,777.7,100,,,Fee Schedule,100% of CMS OPPS Rate,368.23,1049.89,
IMMUNOCYTOLOGY-TC,348700,CDM,310,RC,88312,HCPCS,Outpatient,,,198,138.6,TC,17.61,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,149.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.62,100,,,Fee Schedule,100% of MO Medicaid Rate,66.16,135,,,Fee Schedule,135% of CMS OPPS Rate,97.53,102,,,Fee Schedule,102% MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS rate,97.53,102,,,Fee Schedule,102% of MO Medicaid rate,95.62,100,,,Fee Schedule,100% of MO Medicaid rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.62,100,,,Fee Schedule,100% of MO Medicaid Rate,49,100,,,Fee Schedule,100% of CMS OPPS Rate,49,149.32,
IMMUNOCYTOLOGY-TC,348710,CDM,310,RC,,,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,82.5,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,66,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,22.44,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.44,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22,82.5,
CYTOLOGY-TC,348715,CDM,310,RC,88104,HCPCS,Outpatient,,,121,84.7,TC,18.3,100,,,fee schedule,100% Aetna Market fee schedule,82.28,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,82.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.5,50,,3434,Percent of Total Billed Charges,50% of Total Billed Charges,84.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.51,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,65.8,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,65.8,102,,,Fee Schedule,102% of MO Medicaid rate,64.51,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.51,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.27,84.2,
FLUOROSCOPY UP TO 1 HOUR,541012,CDM,320,RC,76000,HCPCS,Outpatient,,,466,326.2,,15.64,100,,,fee schedule,100% Aetna Market fee schedule,316.88,68,,253.5,Percent of Total Billed Charges,68% of Total Billed Charges,316.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,233,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,48.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,48.1,316.88,
FLUOROSCOPY NEEDLE BIO ASPIR,550416,CDM,320,RC,77002,HCPCS,Outpatient,,,400,280,,27.93,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,272,68,,116.74,Percent of Total Billed Charges,68% of Total Billed Charges,200,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,153.9,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,272,
UROGRAPHY RETROGRADE WO W KUB,550420,CDM,320,RC,74420,HCPCS,Outpatient,,,1128,789.6,26,25.25,100,,,fee schedule,100% Aetna Market fee schedule,767.04,68,,613.63,Percent of Total Billed Charges,68% of Total Billed Charges,767.04,68,,4.86,Percent of Total Billed Charges,68% of Total Billed Charges,564,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,92.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,767.04,
FLUORO GUID CENT VEN DEV IMP,550432,CDM,320,RC,77001,HCPCS,Outpatient,,,116,81.2,,18.83,100,,,fee schedule,100% Aetna Market fee schedule,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,78.88,68,,4.86,Percent of Total Billed Charges,68% of Total Billed Charges,58,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,139.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58,139.04,
US TRANSRECTAL,890268,CDM,320,RC,76872,HCPCS,Outpatient,,,335,234.5,26,33.34,100,,,fee schedule,100% Aetna Market fee schedule,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,227.8,68,,1298.69,Percent of Total Billed Charges,68% of Total Billed Charges,167.5,50,,66,Percent of Total Billed Charges,50% of Total Billed Charges,290.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,290.66,
US GUIDE NEEDLE PLACEMENT,890386,CDM,320,RC,76942,HCPCS,Outpatient,,,107,74.9,26,27.76,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,72.76,68,,8.51,Percent of Total Billed Charges,68% of Total Billed Charges,53.5,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.68,75,
FLUOROSCOPY NEEDLE BIO ASPIR,59907,CDM,320,RC,77002,HCPCS,Outpatient,,,400,280,,27.93,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,272,68,,4.86,Percent of Total Billed Charges,68% of Total Billed Charges,200,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,153.9,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,272,
T-TUBE CHOLANGIOGRAM,520560,CDM,320,RC,74320,HCPCS,Outpatient,,,1661,1162.7,,,,,,Other,Not Seperately Reimbusable,1129.48,68,,903.58,Percent of Total Billed Charges,68% of Total Billed Charges,1129.48,68,,903.58,Percent of Total Billed Charges,68% of Total Billed Charges,830.5,50,,664.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,1129.48,
ANKLE; RIGHT; ANTER&LATERAL; X,810300,CDM,320,RC,73600,HCPCS,Outpatient,,,248,173.6,RT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
ANKLE; LEFT; ANTER&LATERAL; X-,810301,CDM,320,RC,73600,HCPCS,Outpatient,,,248,173.6,LT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
ANKLE; BILATERAL; ANTER&LATERA,810302,CDM,320,RC,73600,HCPCS,Outpatient,,,248,173.6,50,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
ANKLE; RIGHT; COMPLETE; X-RAY,810350,CDM,320,RC,73610,HCPCS,Outpatient,,,248,173.6,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,48.68,168.64,
ANKLE; LEFT; COMPLETE; X-RAY,810351,CDM,320,RC,73610,HCPCS,Outpatient,,,248,173.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,48.68,168.64,
ANKLE; BILATERAL; COMPLETE; X-,810352,CDM,320,RC,73610,HCPCS,Outpatient,,,198,138.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,48.68,134.64,
SPINE; CERVICAL; ANTER.&LATERA,810360,CDM,320,RC,72040,HCPCS,Outpatient,,,248,173.6,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,168.64,
CLAVICLE; RIGHT; COMPLETE; X-R,810400,CDM,320,RC,73000,HCPCS,Outpatient,,,248,173.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
CLAVICLE; LEFT; COMPLETE; X-RA,810401,CDM,320,RC,73000,HCPCS,Outpatient,,,248,173.6,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
CLAVICLE; BILATERAL; COMPLETE;,810402,CDM,320,RC,73000,HCPCS,Outpatient,,,198,138.6,50,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,134.64,
ELBOW; RIGHT; COMPLETE; X-RAY,810450,CDM,320,RC,73080,HCPCS,Outpatient,,,248,173.6,RT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
FACIAL BONES;RIGHT;LESS THAN 3,810451,CDM,320,RC,70140,HCPCS,Outpatient,,,248,173.6,RT,10.13,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,168.64,
FACIAL BONES;LEFT;LESS THAN 3V,810452,CDM,320,RC,70140,HCPCS,Outpatient,,,248,173.6,LT,10.13,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,168.64,
"FACIAL BONES;BILAT,LESS THAN 3",810453,CDM,320,RC,70140,HCPCS,Outpatient,,,248,173.6,50,10.13,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,168.64,
ELBOW; RIGHT; ANTER&LATERAL; X,810455,CDM,320,RC,73070,HCPCS,Outpatient,,,248,173.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
ELBOW; LEFT; ANTER&LATERAL; X-,810456,CDM,320,RC,73070,HCPCS,Outpatient,,,248,173.6,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
ELBOW; BILATERAL; ANTER.&LATER,810457,CDM,320,RC,73070,HCPCS,Outpatient,,,198,138.6,50,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,134.64,
ELBOW; LEFT; COMPLETE; X-RAY,810458,CDM,320,RC,73080,HCPCS,Outpatient,,,248,173.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,168.64,
ELBOW; BILATERAL; COMPLETE; X-,810459,CDM,320,RC,73080,HCPCS,Outpatient,,,198,138.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,134.64,
FACIAL BONES;RIGHT;COMPLETE;X-,810460,CDM,320,RC,70150,HCPCS,Outpatient,,,334,233.8,RT,12.96,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,60.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60.12,227.12,
FACIAL BONES;LEFT;COMPLETE;X-R,810461,CDM,320,RC,70150,HCPCS,Outpatient,,,334,233.8,LT,12.96,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,60.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60.12,227.12,
FACIAL BONES;BILAT;COMPLETE;X-,810462,CDM,320,RC,70150,HCPCS,Outpatient,,,334,233.8,50,12.96,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,60.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60.12,227.12,
FEMUR; RIGHT; ANTER&LATERAL; X,810500,CDM,320,RC,73551,HCPCS,Outpatient,,,248,173.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FEMUR; LEFT; ANTER&LATERAL; X-,810501,CDM,320,RC,73551,HCPCS,Outpatient,,,248,173.6,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FEMUR; BILATERAL; ANTER&LATERA,810502,CDM,320,RC,73551,HCPCS,Outpatient,,,248,173.6,50,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FINGER; LEFT THUMB; MIN. 2 VIE,810550,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,FA,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; LEFT 2ND; MIN. 2 VIEWS,810551,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F1,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; LEFT 3RD; MIN. 2 VIEWS,810552,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F2,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; LEFT 4TH; MIN. 2 VIEWS,810553,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F3,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; LEFT 5TH; MIN. 2 VIEWS,810554,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F4,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; RIGHT THUMB; MIN. 2 VI,810555,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F5,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; RIGHT 2ND; MIN. 2 VIEW,810556,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F6,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; RIGHT 3RD; MIN. 2 VIEW,810557,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F7,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; RIGHT 4TH; MIN. 2 VIEW,810558,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F8,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FINGER; RIGHT 5TH; MIN. 2 VIEW,810559,CDM,320,RC,73140,HCPCS,Outpatient,,,248,173.6,F9,6.97,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.4,168.64,
FOOT; RIGHT; COMPLETE; X-RAY,810600,CDM,320,RC,73630,HCPCS,Outpatient,,,248,173.6,,8.4,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
FOOT; LEFT; COMPLETE; X-RAY,810601,CDM,320,RC,73630,HCPCS,Outpatient,,,248,173.6,LT,8.4,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
FOOT; BILATERAL; COMPLETE; X-R,810602,CDM,320,RC,73630,HCPCS,Outpatient,,,198,138.6,50,8.4,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,134.64,
FOOT; RIGHT; ANTER&LATERAL; X-,810603,CDM,320,RC,73620,HCPCS,Outpatient,,,248,173.6,RT,7.7,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FOOT; LEFT; ANT&LATERAL; X-RAY,810604,CDM,320,RC,73620,HCPCS,Outpatient,,,248,173.6,LT,7.7,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FOOT; BILATERAL; ANT&LATERAL;,810605,CDM,320,RC,73620,HCPCS,Outpatient,,,248,173.6,50,7.7,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,168.64,
FOREARM; RIGHT; ANTER&LATERAL;,810650,CDM,320,RC,73090,HCPCS,Outpatient,,,248,173.6,RT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,168.64,
FOREARM; LEFT; ANTER&LATERAL;,810651,CDM,320,RC,73090,HCPCS,Outpatient,,,248,173.6,LT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,168.64,
FOREARM; BILATERAL; ANTER&LATE,810652,CDM,320,RC,73090,HCPCS,Outpatient,,,248,173.6,50,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,168.64,
FULL BODY INFANT,810660,CDM,320,RC,77076,HCPCS,Outpatient,,,350,245,,34.65,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,175,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,127.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,238,
HAND; RIGHT; MIN.3 VIEWS; X-RA,810700,CDM,320,RC,73130,HCPCS,Outpatient,,,248,173.6,RT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,168.64,
HAND; LEFT; MIN. 3 VIEWS; X-RA,810701,CDM,320,RC,73130,HCPCS,Outpatient,,,248,173.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,168.64,
HAND; BILATERAL; MIN. 3 VIEWS;,810702,CDM,320,RC,73130,HCPCS,Outpatient,,,248,173.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,168.64,
HAND; RIGHT; 2 VIEWS; X-RAY,810703,CDM,320,RC,73120,HCPCS,Outpatient,,,198,138.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,40.66,134.64,
HAND; LEFT; 2 VIEWS; X-RAY,810704,CDM,320,RC,73120,HCPCS,Outpatient,,,334,233.8,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,40.66,227.12,
HAND; BILATERAL; 2 VIEWS; X-RA,810705,CDM,320,RC,73120,HCPCS,Outpatient,,,334,233.8,50,8.38,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,40.66,227.12,
CALCANEUS; RIGHT; MIN. 2 VIEWS,810750,CDM,320,RC,73650,HCPCS,Outpatient,,,248,173.6,RT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.1,168.64,
CALCANEUS; LEFT; MIN. 2 VIEWS;,810751,CDM,320,RC,73650,HCPCS,Outpatient,,,198,138.6,LT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.1,134.64,
CALCANEUS; BILATERAL; MIN.2 VI,810752,CDM,320,RC,73650,HCPCS,Outpatient,,,198,138.6,50,8.04,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.1,134.64,
HIP; RIGHT; COMPLETE;MIN. 2 VI,810800,CDM,320,RC,73502,HCPCS,Outpatient,,,248,173.6,RT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,63.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,63.54,168.64,
HIP; LEFT; COMPLETE;MIN. 2 VIE,810801,CDM,320,RC,73502,HCPCS,Outpatient,,,248,173.6,LT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,63.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,63.54,168.64,
HIPS; BILATERAL; MIN. 2 VIEWS,810805,CDM,320,RC,73521,HCPCS,Outpatient,,,334,233.8,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,52.68,227.12,
HIP; RIGHT; DURING OP PROC; X-,810810,CDM,320,RC,73501,HCPCS,Outpatient,,,332,232.4,RT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,225.76,
HIP; LEFT; DURING OP PROC; X-R,810811,CDM,320,RC,73501,HCPCS,Outpatient,,,332,232.4,LT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,225.76,
PELVIS&HIPS;INFANT/CHILD;MIN.2,810815,CDM,320,RC,73540,HCPCS,Outpatient,,,198,138.6,,,,,,Other,Not Seperately Reimbusable,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,134.64,
HUMERUS; RIGHT; MIN. 2 VIEWS;,810850,CDM,320,RC,73060,HCPCS,Outpatient,,,248,173.6,RT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.82,168.64,
HUMERUS; LEFT; MIN. 2 VIEWS; X,810851,CDM,320,RC,73060,HCPCS,Outpatient,,,248,173.6,LT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.82,168.64,
HUMERUS; BILATERAL; MIN. 2 VIE,810852,CDM,320,RC,73060,HCPCS,Outpatient,,,248,173.6,50,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.82,168.64,
KNEE;RIGHT;ANT&LATW/OBLIQ;MIN.,810900,CDM,320,RC,73562,HCPCS,Outpatient,,,198,138.6,RT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,134.64,
KNEE;LEFT;ANT&LAT.W/OBLIQ;MIN.,810901,CDM,320,RC,73562,HCPCS,Outpatient,,,198,138.6,LT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,134.64,
KNEE;BILAT;ANT&LAT.W/OBLIQ;MIN,810902,CDM,320,RC,73562,HCPCS,Outpatient,,,198,138.6,50,9.43,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,134.64,
KNEE; RIGHT; ANTER&LATERAL; X-,810903,CDM,320,RC,73560,HCPCS,Outpatient,,,248,173.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
KNEE; LEFT; ANTER&LATERAL; X-R,810904,CDM,320,RC,73560,HCPCS,Outpatient,,,248,173.6,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
KNEE; BILATERAL; ANTER&LATERAL,810905,CDM,320,RC,73560,HCPCS,Outpatient,,,248,173.6,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
KNEE; RIGHT; COMPLETE W/OBLIQ;,810910,CDM,320,RC,73564,HCPCS,Outpatient,,,334,233.8,RT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,62.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,62.4,227.12,
KNEE; LEFT; COMPLETE W/OBLIQ;,810911,CDM,320,RC,73564,HCPCS,Outpatient,,,334,233.8,LT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,62.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,62.4,227.12,
KNEE; BILATERAL; COMPLETE W/OB,810912,CDM,320,RC,73564,HCPCS,Outpatient,,,198,138.6,50,11.2,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,62.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,62.4,134.64,
KNEE; BOTH; STANDING; ANTER; X,810913,CDM,320,RC,73565,HCPCS,Outpatient,,,198,138.6,,8.72,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,134.64,
SPINE;LUMBOSACRAL;COMPLETE;W/O,810916,CDM,320,RC,72110,HCPCS,Outpatient,,,334,233.8,,12.96,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,68.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,68.12,227.12,
LOWER EXTREMITY;INFANT;MIN.2 V,810918,CDM,320,RC,73592,HCPCS,Outpatient,,,248,173.6,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
PELVIMETRY,810925,CDM,320,RC,74710,HCPCS,Outpatient,,,332,232.4,,,,,,Other,Not Seperately Reimbusable,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,225.76,
PELVIS; ANTEROPOSTERIOR ONLY;,810950,CDM,320,RC,72170,HCPCS,Outpatient,,,334,233.8,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,33.8,227.12,
PELVIS; COMPLETE; X-RAY,810951,CDM,320,RC,72190,HCPCS,Outpatient,,,334,233.8,,12.61,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,52.1,227.12,
SCAPULA; RIGHT; COMPLETE; X-RA,811000,CDM,320,RC,73010,HCPCS,Outpatient,,,248,173.6,RT,9.08,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,168.64,
SCAPULA; LEFT; COMPLETE; X-RAY,811001,CDM,320,RC,73010,HCPCS,Outpatient,,,248,173.6,LT,9.08,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,168.64,
SCAPULA; BILATERAL; COMPLETE;,811002,CDM,320,RC,73010,HCPCS,Outpatient,,,344,240.8,50,9.08,100,,,fee schedule,100% Aetna Market fee schedule,233.92,68,,187.14,Percent of Total Billed Charges,68% of Total Billed Charges,233.92,68,,187.14,Percent of Total Billed Charges,68% of Total Billed Charges,172,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,233.92,
SHOULDER; RIGHT; COMPLETE; X-R,811050,CDM,320,RC,73030,HCPCS,Outpatient,,,248,173.6,RT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,168.64,
SHOULDER; LEFT; COMPLETE; X-RA,811051,CDM,320,RC,73030,HCPCS,Outpatient,,,248,173.6,LT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,168.64,
SHOULDER; BILATERAL; COMPLETE;,811052,CDM,320,RC,73030,HCPCS,Outpatient,,,198,138.6,50,9.43,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,134.64,
SHOULDER; RIGHT; ONE VIEW; X-R,811054,CDM,320,RC,73020,HCPCS,Outpatient,,,248,173.6,RT,7.69,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.66,168.64,
SHOULDER; LEFT; ONE VIEW; X-RA,811055,CDM,320,RC,73020,HCPCS,Outpatient,,,248,173.6,LT,7.69,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.66,168.64,
SHOULDER; BILATERAL; ONE VIEW;,811056,CDM,320,RC,73020,HCPCS,Outpatient,,,248,173.6,50,7.69,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,24.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.66,168.64,
SWALLOWING FUNCTION,811064,CDM,320,RC,74230,HCPCS,Outpatient,,,547,382.9,,26.55,100,,,fee schedule,100% Aetna Market fee schedule,371.96,68,,297.57,Percent of Total Billed Charges,68% of Total Billed Charges,371.96,68,,297.57,Percent of Total Billed Charges,68% of Total Billed Charges,273.5,50,,218.8,Percent of Total Billed Charges,50% of Total Billed Charges,171.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,371.96,
TIBIA & FIBULA;RIGHT;ANTER&LAT,811100,CDM,320,RC,73590,HCPCS,Outpatient,,,248,173.6,RT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
TIBIA & FIBULA;LEFT;ANTER&LATE,811101,CDM,320,RC,73590,HCPCS,Outpatient,,,248,173.6,LT,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
TIBIA & FIBULA;BILATERAL;ANT&L,811102,CDM,320,RC,73590,HCPCS,Outpatient,,,248,173.6,50,8.04,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
TOE; LEFT GREAT; MIN. 2 VIEWS;,811150,CDM,320,RC,73660,HCPCS,Outpatient,,,248,173.6,TA,6.63,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,168.64,
TOE; LEFT 2ND; MIN. 2 VIEWS; X,811151,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T1,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
TOE; LEFT 3RD; MIN. 2 VIEWS; X,811152,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T2,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
TOE; LEFT 4TH; MIN. 2 VIEWS; X,811153,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T3,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
TOE; LEFT 5TH; MIN. 2 VIEWS; X,811154,CDM,320,RC,73660,HCPCS,Outpatient,,,248,173.6,T4,6.63,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,168.64,
TOE; RIGHT GREAT; MIN. 2 VIEWS,811155,CDM,320,RC,73660,HCPCS,Outpatient,,,248,173.6,T5,6.63,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,168.64,
TOE; RIGHT 2ND; MIN. 2 VIEWS;,811156,CDM,320,RC,73660,HCPCS,Outpatient,,,248,173.6,T6,6.63,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,168.64,
TOE; RIGHT 3RD; MIN. 2 VIEWS;,811157,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T7,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
TOE; RIGHT 4TH; MIN. 2 VIEWS;,811158,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T8,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
TOE; RIGHT 5TH; MIN. 2 VIEWS;,811159,CDM,320,RC,73660,HCPCS,Outpatient,,,198,138.6,T9,6.63,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,134.64,
WRIST; RIGHT; COMPLETE; X-RAY,811200,CDM,320,RC,73110,HCPCS,Outpatient,,,248,173.6,RT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,168.64,
WRIST; LEFT; COMPLETE; X-RAY,811201,CDM,320,RC,73110,HCPCS,Outpatient,,,248,173.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,168.64,
WRIST; BILATERAL; COMPLETE; X-,811202,CDM,320,RC,73110,HCPCS,Outpatient,,,248,173.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,168.64,
HIP; RIGHT; ONE VIEW; X-RAY,811500,CDM,320,RC,73501,HCPCS,Outpatient,,,248,173.6,RT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
HIP; LEFT; ONE VIEW; X-RAY,811501,CDM,320,RC,73501,HCPCS,Outpatient,,,248,173.6,LT,9.43,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
"UROGRAPHY, RETROGRADE; X-RAY",811650,CDM,320,RC,74420,HCPCS,Outpatient,,,33,23.1,26,25.25,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,16.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,16.5,469.55,
"CYSTOGRAPHY, MIN. 3 VIEWS; S&I",811700,CDM,320,RC,74430,HCPCS,Outpatient,,,755,528.5,,15.44,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,513.4,
"URETHROCYSTOGRAPHY, RETROGRADE",811701,CDM,320,RC,74450,HCPCS,Outpatient,,,755,528.5,,16.14,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,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,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,513.4,
"URETHROCYSTOGRAPHY, VOIDING,S&",811702,CDM,320,RC,74455,HCPCS,Outpatient,,,755,528.5,,15.8,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,152.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,513.4,
DXA BONE DENSITY STUDY,811800,CDM,320,RC,77080,HCPCS,Outpatient,,,556,389.2,,9.81,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,278,50,,222.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,378.08,
ABDOMEN; SINGLE ANTER; X-RAY,811900,CDM,320,RC,74018,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.24,168.64,
ABDOMEN; ANTER/OBLIQUE/CONE; X,811901,CDM,320,RC,74010,HCPCS,Outpatient,,,198,138.6,,,,,,Other,Not Seperately Reimbusable,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,134.64,
ABDOMEN; COMPLETE; X-RAY,811925,CDM,320,RC,74019,HCPCS,Outpatient,,,334,233.8,,11.55,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,227.12,
ACROMIOCLAVICULAR JOINTS;BILAT,811926,CDM,320,RC,73050,HCPCS,Outpatient,,,198,138.6,,9.43,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,34.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,34.38,134.64,
ABDOMEN; COMPLETE ACUTE SERIES,811927,CDM,320,RC,74022,HCPCS,Outpatient,,,334,233.8,,15.78,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,60.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60.12,227.12,
COLON; AIR CONTR.W/ BARIUM; X-,811950,CDM,320,RC,74280,HCPCS,Outpatient,,,623,436.1,,62.3,100,,,fee schedule,100% Aetna Market fee schedule,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,275.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,423.64,
COLON; BARIUM ENEMA; X-RAY,812000,CDM,320,RC,74270,HCPCS,Outpatient,,,385,269.5,,51.14,100,,,fee schedule,100% Aetna Market fee schedule,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,Percent of Total Billed Charges,50% of Total Billed Charges,180.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,261.8,
ESOPHAGUS; X-RAY,812050,CDM,320,RC,74220,HCPCS,Outpatient,,,248,173.6,,29.73,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,119.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,224.33,
PHARYNX &/OR CERVICAL ESOPHAGU,812051,CDM,320,RC,74210,HCPCS,Outpatient,,,385,269.5,,29.37,100,,,fee schedule,100% Aetna Market fee schedule,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,Percent of Total Billed Charges,50% of Total Billed Charges,115.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,261.8,
BREAST-LOCALIZATION,812077,CDM,320,RC,19081,HCPCS,Outpatient,,,535,374.5,,141.64,100,,,fee schedule,100% Aetna Market fee schedule,363.8,68,,291.04,Percent of Total Billed Charges,68% of Total Billed Charges,363.8,68,,291.04,Percent of Total Billed Charges,68% of Total Billed Charges,267.5,50,,214,Percent of Total Billed Charges,50% of Total Billed Charges,307.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,75,1979.55,
BREAST-SURG SPECIMEN,812078,CDM,320,RC,76098,HCPCS,Outpatient,,,1661,1162.7,,15.73,100,,,fee schedule,100% Aetna Market fee schedule,1129.48,68,,903.58,Percent of Total Billed Charges,68% of Total Billed Charges,1129.48,68,,903.58,Percent of Total Billed Charges,68% of Total Billed Charges,830.5,50,,664.4,Percent of Total Billed Charges,50% of Total Billed Charges,47.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.05,100,,,Fee Schedule,100% of MO Medicaid Rate,673.58,135,,,Fee Schedule,135% of CMS OPPS Rate,458.03,102,,,Fee Schedule,102% MO Medicaid rate,498.94,100,,,Fee Schedule,100% of CMS OPPS rate,458.03,102,,,Fee Schedule,102% of MO Medicaid rate,449.05,100,,,Fee Schedule,100% of MO Medicaid rate,498.94,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,449.05,100,,,Fee Schedule,100% of MO Medicaid Rate,498.94,100,,,Fee Schedule,100% of CMS OPPS Rate,47.54,1129.48,
SPINE CERVICAL; MIN. 3 VIEWS;,812150,CDM,320,RC,72050,HCPCS,Outpatient,,,334,233.8,,13.66,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,70.4,227.12,
CHEST XRY PA & LATRL,812265,CDM,320,RC,71046,HCPCS,Outpatient,,,248,173.6,,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,168.64,
SACRUM & COCCYX; MIN. 2 VIEWS;,812300,CDM,320,RC,72220,HCPCS,Outpatient,,,248,173.6,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.82,168.64,
SPINE; THORACIC; ANTER.&LATERA,812350,CDM,320,RC,72070,HCPCS,Outpatient,,,334,233.8,,10.15,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,227.12,
FLUOROSCOPY,812423,CDM,320,RC,76000,HCPCS,Outpatient,,,17,11.9,26,15.64,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,8.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,299.18,
FLUOROSCOPY TECH,812424,CDM,320,RC,76000,HCPCS,Outpatient,,,376,263.2,TC,15.64,100,,,fee schedule,100% Aetna Market fee schedule,255.68,68,,204.54,Percent of Total Billed Charges,68% of Total Billed Charges,255.68,68,,204.54,Percent of Total Billed Charges,68% of Total Billed Charges,188,50,,150.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,48.1,299.18,
FLUOROSCOPIC LOCAL FOR NEEDLE,812425,CDM,320,RC,77002,HCPCS,Outpatient,,,279,195.3,,27.93,100,,,fee schedule,100% Aetna Market fee schedule,189.72,68,,151.78,Percent of Total Billed Charges,68% of Total Billed Charges,189.72,68,,151.78,Percent of Total Billed Charges,68% of Total Billed Charges,139.5,50,,111.6,Percent of Total Billed Charges,50% of Total Billed Charges,153.9,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,189.72,
RADIOL.EXAM FOR FOREIGN BODY;C,812426,CDM,320,RC,76010,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.1,168.64,
BONE AGE STUDIES; X-RAY,812427,CDM,320,RC,77072,HCPCS,Outpatient,,,198,138.6,,9.45,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,29.24,134.64,
BONE LENGTH STUDIES; X-RAY,812428,CDM,320,RC,77073,HCPCS,Outpatient,,,198,138.6,,13.61,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,55.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,55.54,134.64,
FLUOROSCOPIC-LOCAL,812430,CDM,320,RC,77003,HCPCS,Outpatient,,,72,50.4,TC,29.73,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,132.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,132.18,
FLURO-LOCAL BY XRAY,812435,CDM,320,RC,77002,HCPCS,Outpatient,,,39,27.3,26,27.93,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,78,
"UROGRAPHY, INFUSION, DRIP TECH",812600,CDM,320,RC,74410,HCPCS,Outpatient,,,755,528.5,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,204.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,513.4,
"UROGRAPHY, INTRAVENOUS; X-RAY",812601,CDM,320,RC,74400,HCPCS,Outpatient,,,755,528.5,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,192.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,513.4,
"UROGRAPHY, ANTERGRADE, S&I; X-",812651,CDM,320,RC,74425,HCPCS,Outpatient,,,755,528.5,,24.55,100,,,fee schedule,100% Aetna Market fee schedule,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,513.4,68,,410.72,Percent of Total Billed Charges,68% of Total Billed Charges,377.5,50,,302,Percent of Total Billed Charges,50% of Total Billed Charges,192.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,75,513.4,
SPINE; LUMBOSACRAL; ANTER.&LAT,812800,CDM,320,RC,72100,HCPCS,Outpatient,,,334,233.8,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,227.12,
MANDIBLE; PARTIAL; X-RAY,812850,CDM,320,RC,70100,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,52.1,168.64,
MANDIBLE; COMPLETE; X-RAY,812860,CDM,320,RC,70110,HCPCS,Outpatient,,,248,173.6,,12.27,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,54.96,168.64,
MASTOIDS;LESS THAN 3 VIEWS/SID,812890,CDM,320,RC,70120,HCPCS,Outpatient,,,198,138.6,RT,9.09,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,134.64,
MASTOIDS; LESS THAN 3 VIEWS/SI,812891,CDM,320,RC,70120,HCPCS,Outpatient,,,198,138.6,LT,9.09,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,134.64,
MASTOIDS;LESS THAN 3VIEWS/SIDE,812892,CDM,320,RC,70120,HCPCS,Outpatient,,,198,138.6,50,9.09,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,134.64,
MASTOIDS; RIGHT; COMPLETE; X-R,812900,CDM,320,RC,70130,HCPCS,Outpatient,,,198,138.6,RT,17.14,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,78.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,134.64,
MASTOIDS; LEFT; COMPLETE; X-RA,812901,CDM,320,RC,70130,HCPCS,Outpatient,,,198,138.6,LT,17.14,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,78.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,134.64,
MASTOIDS; BILATERAL; COMPLETE;,812902,CDM,320,RC,70130,HCPCS,Outpatient,,,198,138.6,50,17.14,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,78.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,134.64,
"NECK,SOFT TISSUE X-RAY",812945,CDM,320,RC,70360,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,168.64,
NASAL BONES;RIGHT;COMPLETE;X-R,813000,CDM,320,RC,70160,HCPCS,Outpatient,,,198,138.6,RT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,134.64,
NASAL BONES;LEFT;COMPLETE;X-RA,813001,CDM,320,RC,70160,HCPCS,Outpatient,,,248,173.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,168.64,
NASAL BONES;BILATERAL;COMPLETE,813002,CDM,320,RC,70160,HCPCS,Outpatient,,,248,173.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,168.64,
OPTIC FORAMINA;RIGHT;X-RAY,813075,CDM,320,RC,70190,HCPCS,Outpatient,,,198,138.6,RT,11.18,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.38,134.64,
OPTIC FORAMINA;LEFT;X-RAY,813076,CDM,320,RC,70190,HCPCS,Outpatient,,,198,138.6,LT,11.18,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.38,134.64,
OPTIC FORAMINA;BILATERAL;X-RAY,813077,CDM,320,RC,70190,HCPCS,Outpatient,,,198,138.6,50,11.18,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.38,134.64,
ORBIT;RIGHT;X-RAY,813100,CDM,320,RC,70200,HCPCS,Outpatient,,,248,173.6,RT,14.01,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,168.64,
ORBIT;LEFT;X-RAY,813101,CDM,320,RC,70200,HCPCS,Outpatient,,,248,173.6,LT,14.01,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,168.64,
ORBITS;BILATERAL;X-RAY,813102,CDM,320,RC,70200,HCPCS,Outpatient,,,198,138.6,50,14.01,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,134.64,
PORTABLE CHEST-XRAY,813150,CDM,320,RC,71045,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.8,168.64,
RIBS; BILATERAL; THREE VIEWS;,813200,CDM,320,RC,71110,HCPCS,Outpatient,,,334,233.8,,14.37,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,52.1,227.12,
RIBS W/CHEST;BILATERAL;MIN.4 V,813203,CDM,320,RC,71111,HCPCS,Outpatient,,,334,233.8,,15.78,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,64.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,64.12,227.12,
RIBS; RIGHT; X-RAY,813210,CDM,320,RC,71100,HCPCS,Outpatient,,,248,173.6,RT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
RIBS; LEFT; X-RAY,813211,CDM,320,RC,71100,HCPCS,Outpatient,,,248,173.6,LT,11.2,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,168.64,
RIBS W/CHEST;RIGHT;MIN.3 VIEWS,813215,CDM,320,RC,71101,HCPCS,Outpatient,,,334,233.8,RT,13.32,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,227.12,
RIBS W/CHEST; LEFT; MIN.3 VIEW,813216,CDM,320,RC,71101,HCPCS,Outpatient,,,334,233.8,LT,13.32,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,50.96,227.12,
SACROILIAC JOINTS;RIGHT;MIN.3V,813235,CDM,320,RC,72202,HCPCS,Outpatient,,,334,233.8,RT,11.22,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,49.24,227.12,
SACROILIAC JOINTS;LEFT;MIN.3VI,813236,CDM,320,RC,72202,HCPCS,Outpatient,,,334,233.8,LT,11.22,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,49.24,227.12,
SACROILIAC JOINTS;BILAT;MIN.3V,813237,CDM,320,RC,72202,HCPCS,Outpatient,,,334,233.8,50,11.22,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,49.24,227.12,
"HYSTEROSALPINGOGRAPHY, S&I; X-",813250,CDM,320,RC,74740,HCPCS,Outpatient,,,926,648.2,,18.9,100,,,fee schedule,100% Aetna Market fee schedule,629.68,68,,503.74,Percent of Total Billed Charges,68% of Total Billed Charges,629.68,68,,503.74,Percent of Total Billed Charges,68% of Total Billed Charges,463,50,,370.4,Percent of Total Billed Charges,50% of Total Billed Charges,129.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75,629.68,
SINUSES;COMPLETE;RIGHT;MIN.3VI,813300,CDM,320,RC,70220,HCPCS,Outpatient,,,248,173.6,RT,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,168.64,
SINUSES;COMPLETE;LEFT;MIN.3VIE,813301,CDM,320,RC,70220,HCPCS,Outpatient,,,248,173.6,LT,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,168.64,
SINUSES;COMPLETE;BILAT;MIN.3VI,813302,CDM,320,RC,70220,HCPCS,Outpatient,,,248,173.6,50,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,168.64,
SKULL; COMPLETE; X-RAY,813350,CDM,320,RC,70260,HCPCS,Outpatient,,,332,232.4,,14.01,100,,,fee schedule,100% Aetna Market fee schedule,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,Percent of Total Billed Charges,50% of Total Billed Charges,53.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,53.82,225.76,
SKULL; LESS THAN 4 VIEWS; X-RA,813354,CDM,320,RC,70250,HCPCS,Outpatient,,,334,233.8,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,227.12,
SMALL BOWEL SERIES,813400,CDM,320,RC,74250,HCPCS,Outpatient,,,547,382.9,,39.92,100,,,fee schedule,100% Aetna Market fee schedule,371.96,68,,297.57,Percent of Total Billed Charges,68% of Total Billed Charges,371.96,68,,297.57,Percent of Total Billed Charges,68% of Total Billed Charges,273.5,50,,218.8,Percent of Total Billed Charges,50% of Total Billed Charges,144.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,371.96,
SMALL BOWEL SERIES;ENTEROCLYSI,813401,CDM,320,RC,74251,HCPCS,Outpatient,,,623,436.1,,58.08,100,,,fee schedule,100% Aetna Market fee schedule,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,527.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,527.92,
STERNOCLAVICULAR JOINTS;RIGHT;,813405,CDM,320,RC,71130,HCPCS,Outpatient,,,198,138.6,RT,10.86,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,53.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,53.26,134.64,
STERNOCLAVICULAR JOINTS;LEFT;M,813406,CDM,320,RC,71130,HCPCS,Outpatient,,,198,138.6,LT,10.86,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,53.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,53.26,134.64,
STERNOCLAVICULAR JOINTS;BILAT;,813407,CDM,320,RC,71130,HCPCS,Outpatient,,,198,138.6,50,10.86,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,53.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,53.26,134.64,
SPINE; ENTIRE; ANTER.&LATERAL;,813408,CDM,320,RC,72010,HCPCS,Outpatient,,,332,232.4,,,,,,Other,Not Seperately Reimbusable,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,225.76,
SPINE; SINGLE VIEW; X-RAY,813409,CDM,320,RC,72020,HCPCS,Outpatient,,,198,138.6,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.66,134.64,
SPINE; CERVICAL; COMPLETE; X-R,813410,CDM,320,RC,72052,HCPCS,Outpatient,,,334,233.8,,14.73,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,82.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,227.12,
SPINE; THORACOLUMBAR; STANDING,813411,CDM,320,RC,72081,HCPCS,Outpatient,,,248,173.6,,12.96,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,52.1,168.64,
SPINE;THORACIC;ANTER.&LAT.;W/S,813412,CDM,320,RC,72072,HCPCS,Outpatient,,,334,233.8,,11.22,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,227.12,
SPINE; THORACIC; COMPLETE; X-R,813413,CDM,320,RC,72074,HCPCS,Outpatient,,,334,233.8,,12.27,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,227.12,
SPINE; SCOLIOSIS STUDY; X-RAY,813414,CDM,320,RC,72090,HCPCS,Outpatient,,,332,232.4,,,,,,Other,Not Seperately Reimbusable,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,225.76,68,,180.61,Percent of Total Billed Charges,68% of Total Billed Charges,166,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,225.76,
STERNUM; MIN. 2 VIEWS; X-RAY,813450,CDM,320,RC,71120,HCPCS,Outpatient,,,248,173.6,,9.81,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.82,168.64,
TMJ; BILATERAL; X-RAY,813500,CDM,320,RC,70330,HCPCS,Outpatient,,,198,138.6,,11.91,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,71.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,71.56,134.64,
TMJ; RIGHT; X-RAY,813510,CDM,320,RC,70328,HCPCS,Outpatient,,,248,173.6,RT,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,168.64,
TMJ; LEFT; X-RAY,813511,CDM,320,RC,70328,HCPCS,Outpatient,,,248,173.6,LT,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,168.64,
UPPER EXTREMITY;INFANT;MIN.2 V,813549,CDM,320,RC,73092,HCPCS,Outpatient,,,334,233.8,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,227.12,
UPPER GI W/O KUB; X-RAY,813550,CDM,320,RC,74240,HCPCS,Outpatient,,,385,269.5,,39.57,100,,,fee schedule,100% Aetna Market fee schedule,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,Percent of Total Billed Charges,50% of Total Billed Charges,145.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,261.8,
UPPER GI WITH KUB; X-RAY,813551,CDM,320,RC,74241,HCPCS,Outpatient,,,385,269.5,,,,,,Other,Not Seperately Reimbusable,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,261.8,
UPPER GI W/ SMALL BOWEL; X-RAY,813552,CDM,320,RC,74245,HCPCS,Outpatient,,,623,436.1,,,,,,Other,Not Seperately Reimbusable,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,423.64,
UPPER GI AIR CONT.W/BARIUM W/O,813553,CDM,320,RC,74246,HCPCS,Outpatient,,,385,269.5,,44.15,100,,,fee schedule,100% Aetna Market fee schedule,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,Percent of Total Billed Charges,50% of Total Billed Charges,166.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,75,261.8,
UPPER GI AIR CONTR. W/BARIUM W,813554,CDM,320,RC,74247,HCPCS,Outpatient,,,385,269.5,,,,,,Other,Not Seperately Reimbusable,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,261.8,68,,209.44,Percent of Total Billed Charges,68% of Total Billed Charges,192.5,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,261.8,
"UPPER GI W/AIR,BARIUM & SM.BOW",813555,CDM,320,RC,74249,HCPCS,Outpatient,,,623,436.1,,,,,,Other,Not Seperately Reimbusable,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,423.64,
"VENOGRAPHY, EXTREMITY; RIGHT;",813600,CDM,320,RC,75820,HCPCS,Outpatient,,,3055,2138.5,RT,51.36,100,,,fee schedule,100% Aetna Market fee schedule,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,1527.5,50,,1222,Percent of Total Billed Charges,50% of Total Billed Charges,101.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1955.43,135,,,Fee Schedule,135% of CMS OPPS Rate,1329.69,102,,,Fee Schedule,102% MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS rate,1329.69,102,,,Fee Schedule,102% of MO Medicaid rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,2077.4,
"VENOGRAPHY, EXTREMITY;LEFT; S&",813601,CDM,320,RC,75820,HCPCS,Outpatient,,,3055,2138.5,LT,51.36,100,,,fee schedule,100% Aetna Market fee schedule,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,1527.5,50,,1222,Percent of Total Billed Charges,50% of Total Billed Charges,101.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1955.43,135,,,Fee Schedule,135% of CMS OPPS Rate,1329.69,102,,,Fee Schedule,102% MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS rate,1329.69,102,,,Fee Schedule,102% of MO Medicaid rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,2077.4,
"VENOGRAPHY, EXTREMITY; BILATER",813610,CDM,320,RC,75822,HCPCS,Outpatient,,,3055,2138.5,,66.75,100,,,fee schedule,100% Aetna Market fee schedule,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,2077.4,68,,1661.92,Percent of Total Billed Charges,68% of Total Billed Charges,1527.5,50,,1222,Percent of Total Billed Charges,50% of Total Billed Charges,112.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1955.43,135,,,Fee Schedule,135% of CMS OPPS Rate,1329.69,102,,,Fee Schedule,102% MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS rate,1329.69,102,,,Fee Schedule,102% of MO Medicaid rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,1303.62,100,,,Fee Schedule,100% of MO Medicaid Rate,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,75,2077.4,
SINUSES;PARANASAL;RIGHT;>3 VIE,813650,CDM,320,RC,70210,HCPCS,Outpatient,,,248,173.6,RT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
SINUSES;PARANASAL;LEFT;>3 VIEW,813651,CDM,320,RC,70210,HCPCS,Outpatient,,,198,138.6,LT,8.74,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,134.64,
SINUSES;PARANASAL;BILAT;>3 VIE,813652,CDM,320,RC,70210,HCPCS,Outpatient,,,248,173.6,50,8.74,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,168.64,
WRIST; RIGHT; ANTER&LATERAL; X,813700,CDM,320,RC,73100,HCPCS,Outpatient,,,198,138.6,RT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,134.64,
WRIST; LEFT; ANTER&LATERAL; X-,813701,CDM,320,RC,73100,HCPCS,Outpatient,,,198,138.6,LT,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,134.64,
WRIST; BILATERAL; ANTER&LATER;,813702,CDM,320,RC,73100,HCPCS,Outpatient,,,198,138.6,50,8.38,100,,,fee schedule,100% Aetna Market fee schedule,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,44.68,134.64,
XRAY/NOSE,7016000,CDM,320,RC,70160,HCPCS,Outpatient,,,55,38.5,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,50.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.5,110.95,
XRAY/SINUSES LESS THAN 3 VIEWS,7021000,CDM,320,RC,70210,HCPCS,Outpatient,,,39,27.3,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,41.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,110.95,
XRAY/SINUS,7022000,CDM,320,RC,70220,HCPCS,Outpatient,,,83,58.1,,10.86,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,110.95,
XRAY/SKULL 1 VIEW,7025000,CDM,320,RC,70250,HCPCS,Outpatient,,,50,35,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,25,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,46.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,25,134.23,
XRAY/SKULL SERIES,7026000,CDM,320,RC,70260,HCPCS,Outpatient,,,90,63,,14.01,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,53.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,45,134.23,
XRAY/CHEST PA,7101000,CDM,320,RC,71010,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,31.5,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,75,
XRAY/CHEST 2 VIEWS,7102000,CDM,320,RC,71020,HCPCS,Outpatient,,,60,42,,,,,,Other,Not Seperately Reimbusable,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,75,
XRAY/CHEST (SPEC),7103500,CDM,320,RC,71035,HCPCS,Outpatient,,,60,42,,,,,,Other,Not Seperately Reimbusable,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,75,
XRAY/RIB LATERAL,7110000,CDM,320,RC,71100,HCPCS,Outpatient,,,60,42,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,30,110.95,
XRAY/RIBS MINIMUM OF 4 VIEWS,7111000,CDM,320,RC,71110,HCPCS,Outpatient,,,78,54.6,,14.37,100,,,fee schedule,100% Aetna Market fee schedule,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,39,50,,31.2,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,39,134.23,
XRAY/CHEST,7201000,CDM,320,RC,72010,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,55,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,75,
XRAY/SPINE SINGLE VIEW,7202000,CDM,320,RC,72020,HCPCS,Outpatient,,,58,40.6,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,28.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.66,110.95,
XRAY/CERVICAL SPINE,7204000,CDM,320,RC,72040,HCPCS,Outpatient,,,83,58.1,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,110.95,
XRAY/SPINE(SCOLIOSIS),7206900,CDM,320,RC,72069,HCPCS,Outpatient,,,43,30.1,,,,,,Other,Not Seperately Reimbusable,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,21.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,75,
XRAY/SPINE THORACIC 2 VIEWS,7207000,CDM,320,RC,72070,HCPCS,Outpatient,,,72,50.4,,10.15,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36,134.23,
XRAY/SPINE,7208000,CDM,320,RC,72080,HCPCS,Outpatient,,,90,63,,10.5,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,45,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,110.95,
XRAY/LUMBAR SPINE,7210000,CDM,320,RC,72100,HCPCS,Outpatient,,,99,69.3,,11.2,100,,,fee schedule,100% Aetna Market fee schedule,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,49.5,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,134.23,
XRAY/COCCYX,7222000,CDM,320,RC,72220,HCPCS,Outpatient,,,40,28,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,20,110.95,
XRAY/CLAVICLE,7300000,CDM,320,RC,73000,HCPCS,Outpatient,,,60,42,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,30,110.95,
XRAY/SCAPULA,7301000,CDM,320,RC,73010,HCPCS,Outpatient,,,36,25.2,,9.08,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,26.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18,134.23,
XRAY/SHOULDER MINIMUM 2 VIEWS,7303000,CDM,320,RC,73030,HCPCS,Outpatient,,,40,28,,9.43,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,20,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,20,110.95,
XRAY/HUMEROUS,7306000,CDM,320,RC,73060,HCPCS,Outpatient,,,30,21,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,41.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15,110.95,
XRAY/ELBOW 2 VIEWS,7307000,CDM,320,RC,73070,HCPCS,Outpatient,,,37,25.9,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,110.95,
XRAY/ELBOW,7308000,CDM,320,RC,73080,HCPCS,Outpatient,,,39,27.3,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,110.95,
XRAY/FOREARM,7309000,CDM,320,RC,73090,HCPCS,Outpatient,,,39,27.3,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,110.95,
XRAY/WRIST 2 VIEWS,7310000,CDM,320,RC,73100,HCPCS,Outpatient,,,42,29.4,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,44.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,21,110.95,
XRAY/WRIST,7311000,CDM,320,RC,73110,HCPCS,Outpatient,,,80,56,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40,110.95,
XRAY/HAND 3 VIEWS,7313000,CDM,320,RC,73130,HCPCS,Outpatient,,,36,25.2,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,110.95,
XRAY/FINGERS,7314000,CDM,320,RC,73140,HCPCS,Outpatient,,,63,44.1,,6.97,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,31.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,54.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,31.5,110.95,
XRAY/HAND 2 VIEWS,7321000,CDM,320,RC,73210,HCPCS,Outpatient,,,30,21,,,,,,Other,Not Seperately Reimbusable,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15,75,
XRAY/HIP 1 VIEW,7350000,CDM,320,RC,73500,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,17.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,75,
XRAY/HIP,7351000,CDM,320,RC,73510,HCPCS,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,75,
XRAY/FEMUR,7355000,CDM,320,RC,73552,HCPCS,Outpatient,,,60,42,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,30,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,46.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,30,110.95,
XRAY/KNEE 1 OR 2 VIEWS,7356000,CDM,320,RC,73560,HCPCS,Outpatient,,,42,29.4,,8.38,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,21,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,21,110.95,
XRAY/KNEE,7356200,CDM,320,RC,73562,HCPCS,Outpatient,,,39,27.3,,9.43,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,54.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,110.95,
XRAY/ANKLE 2 VIEWS,7360000,CDM,320,RC,73600,HCPCS,Outpatient,,,37,25.9,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,110.95,
XRAY/ANKLE MINIMUM OF 3 VIEWS,7361000,CDM,320,RC,73610,HCPCS,Outpatient,,,83,58.1,,8.74,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,110.95,
XRAY/FOOT 2 VIEWS,7362000,CDM,320,RC,73620,HCPCS,Outpatient,,,36,25.2,,7.7,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,110.95,
XRAY/FOOT,7363000,CDM,320,RC,73630,HCPCS,Outpatient,,,83,58.1,,8.4,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,41.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,110.95,
XRAY/HEEL,7365000,CDM,320,RC,73650,HCPCS,Outpatient,,,30,21,,8.04,100,,,fee schedule,100% Aetna Market fee schedule,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,20.4,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,15,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,36.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15,110.95,
XRAY/TOE MINIMUM OF 2 VIEWS,7366000,CDM,320,RC,73660,HCPCS,Outpatient,,,36,25.2,,6.63,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,39.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,18,110.95,
XRAY/ABDOMEN 1 VIEW,7400000,CDM,320,RC,74000,HCPCS,Outpatient,,,32,22.4,,,,,,Other,Not Seperately Reimbusable,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,16,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,75,
XRAY/ABDOMEN FLAT,7402000,CDM,320,RC,74020,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,37,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37,75,
US UNLISTED DIAG PROCEDURE,890265,CDM,320,RC,76499,HCPCS,Outpatient,,,198,138.6,,,,,,Other,Not Seperately Reimbusable,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,134.64,68,,107.71,Percent of Total Billed Charges,68% of Total Billed Charges,99,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,73.96,134.64,
CHEST;2 VIEWS W/APICAL LORD.PR,812190,CDM,324,RC,71047,HCPCS,Outpatient,,,248,173.6,,13.32,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,168.64,
CHEST;SINGLE VIEW;FRONTAL;X-RA,812200,CDM,324,RC,71045,HCPCS,Outpatient,,,248,173.6,,9.09,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.8,168.64,
CHEST 2 VIEWS,812250,CDM,324,RC,71046,HCPCS,Outpatient,,,248,173.6,,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,168.64,
CHEST;2 VIEWS W/OBLIQUE PROJ.;,812258,CDM,324,RC,71047,HCPCS,Outpatient,,,248,173.6,,13.32,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.95,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,168.64,
CHEST; SPECIAL VIEWS; X-RAY,812260,CDM,324,RC,71046,HCPCS,Outpatient,,,248,173.6,,10.86,100,,,fee schedule,100% Aetna Market fee schedule,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,168.64,68,,134.91,Percent of Total Billed Charges,68% of Total Billed Charges,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,40.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,168.64,
HEMOTX ADMIN SUBQ/IM HORMONAL,893416,CDM,330,RC,,,Outpatient,,,190,133,,,,,,Other,Not Seperately Reimbusable,129.2,68,,103.36,Percent of Total Billed Charges,68% of Total Billed Charges,144.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,95,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,123.5,65,,98.8,Percent of Total Billed Charges,65% of Total Billed Charges,142.5,75,,114,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38,20,,30.4,Percent of Total Billed Charges,20% of Total Billed Charges,114,60,,91.2,Percent of Total Billed Charges,60% of Total Billed Charges,38.76,20.4,,31.01,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38.76,20.4,,31.01,Percent of Total Billed Charges,20.4% of Total Billed Charges,38,20,,30.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,100,100,,,Case Rate,Pays based on per visit rate,38,20,,30.4,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,38,144.4,
CHEMO ADMIN OTHER THAN INFUSIO,201178,CDM,331,RC,X4003,HCPCS,Outpatient,,,148,103.6,,,,,,Other,Not Seperately Reimbusable,100.64,68,,80.51,Percent of Total Billed Charges,68% of Total Billed Charges,112.48,76,,73.98,Percent of Total Billed Charges,76% of Total Billed Charges,74,50,,396.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,300,
INJECT THER DX SUBCU OR IM,201195,CDM,331,RC,96372,HCPCS,Outpatient,,,181,126.7,,13.09,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,137.56,76,,14.69,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,300,
CHEMOTHERAPY ADM SUBCUTANEOUS,5527,CDM,331,RC,96372,HCPCS,Outpatient,,,92,64.4,,13.09,100,,,fee schedule,100% Aetna Market fee schedule,62.56,68,,50.05,Percent of Total Billed Charges,68% of Total Billed Charges,69.92,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,300,
CHEMO ANTI-NEOPL SQ/IM,5899,CDM,331,RC,96401,HCPCS,Outpatient,,,233,163.1,,71.27,100,,,fee schedule,100% Aetna Market fee schedule,158.44,68,,126.75,Percent of Total Billed Charges,68% of Total Billed Charges,177.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,116.5,50,,27.6,Percent of Total Billed Charges,50% of Total Billed Charges,125.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,300,
CHEMO INTRA PERITONEAL,201179,CDM,335,RC,96446,HCPCS,Outpatient,,,865,605.5,,24.91,100,,,fee schedule,100% Aetna Market fee schedule,588.2,68,,470.56,Percent of Total Billed Charges,68% of Total Billed Charges,657.4,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,432.5,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,39.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,39.04,657.4,
CHEMO INFUSION PROLONG PUMP,201180,CDM,335,RC,96416,HCPCS,Outpatient,,,865,605.5,,125.52,100,,,fee schedule,100% Aetna Market fee schedule,588.2,68,,470.56,Percent of Total Billed Charges,68% of Total Billed Charges,657.4,76,,15.23,Percent of Total Billed Charges,76% of Total Billed Charges,432.5,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,220.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,657.4,
CHEMO INFUSION EA ADDL SEQ,201181,CDM,335,RC,96417,HCPCS,Outpatient,,,179,125.3,,62.46,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,136.04,76,,15.23,Percent of Total Billed Charges,76% of Total Billed Charges,89.5,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,111.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,136.04,
CHEMO IV PUSH SING/FIRST DRUG,201182,CDM,335,RC,96409,HCPCS,Outpatient,,,562,393.4,,98.71,100,,,fee schedule,100% Aetna Market fee schedule,382.16,68,,305.73,Percent of Total Billed Charges,68% of Total Billed Charges,427.12,76,,45.15,Percent of Total Billed Charges,76% of Total Billed Charges,281,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,174.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,427.12,
CHEMO IV PUSH AS ADDL DRUG,201183,CDM,335,RC,96411,HCPCS,Outpatient,,,179,125.3,,53.91,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,136.04,76,,43.52,Percent of Total Billed Charges,76% of Total Billed Charges,89.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,95.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,136.04,
CHEMO ADMIN BY BOTH INFUSION A,201184,CDM,335,RC,X4003,HCPCS,Outpatient,,,191,133.7,,,,,,Other,Not Seperately Reimbusable,129.88,68,,103.9,Percent of Total Billed Charges,68% of Total Billed Charges,145.16,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,95.5,50,,26.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.5,145.16,
CHEMO SQ/IM NON HORM ANTI NEOP,201185,CDM,335,RC,96401,HCPCS,Outpatient,,,179,125.3,,71.27,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,136.04,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,89.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,136.04,
CHEMO ADMIN INTRAVENOUS 1HR,201186,CDM,335,RC,96413,HCPCS,Outpatient,,,865,605.5,,128.13,100,,,fee schedule,100% Aetna Market fee schedule,588.2,68,,470.56,Percent of Total Billed Charges,68% of Total Billed Charges,657.4,76,,11.97,Percent of Total Billed Charges,76% of Total Billed Charges,432.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,225.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,657.4,
CHEMO ADMIN INTRAVENOUS EA ADD,201188,CDM,335,RC,96415,HCPCS,Outpatient,,,179,125.3,,27.42,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,136.04,76,,27.2,Percent of Total Billed Charges,76% of Total Billed Charges,89.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,49.4,136.04,
CHEMO SQ/IM HORM ANTI NEOP,201189,CDM,335,RC,96402,HCPCS,Outpatient,,,179,125.3,,31.21,100,,,fee schedule,100% Aetna Market fee schedule,121.72,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,136.04,76,,11.97,Percent of Total Billed Charges,76% of Total Billed Charges,89.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,62.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,62.54,136.04,
NUC.MED. BONE/JOINT IMAGING;WH,520350,CDM,340,RC,78306,HCPCS,Outpatient,,,1089,762.3,,41.37,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,394.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
NUC.MED. BONE/JOINT IMAGING;LI,520351,CDM,340,RC,78300,HCPCS,Outpatient,,,1089,762.3,,30.78,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,157.6,Percent of Total Billed Charges,50% of Total Billed Charges,305.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
NUC.MED. BONE/JOINT IMAGING;3,520352,CDM,340,RC,78315,HCPCS,Outpatient,,,1089,762.3,,49.1,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,463.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
NUC.MED. CARDIAC BLOOD POOL IM,520360,CDM,340,RC,78472,HCPCS,Outpatient,,,1346,942.2,,47.68,100,,,fee schedule,100% Aetna Market fee schedule,915.28,68,,732.22,Percent of Total Billed Charges,68% of Total Billed Charges,915.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,673,50,,186,Percent of Total Billed Charges,50% of Total Billed Charges,283.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,283.94,915.28,
NUC.MED. GASTRIC EMPTYING STUD,520370,CDM,340,RC,78264,HCPCS,Outpatient,,,1089,762.3,,38.53,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,169.6,Percent of Total Billed Charges,50% of Total Billed Charges,456.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
NUC.MED. ACUTE VENOUS THROMBOS,520380,CDM,340,RC,78456,HCPCS,Outpatient,,,880,616,,48.73,100,,,fee schedule,100% Aetna Market fee schedule,598.4,68,,478.72,Percent of Total Billed Charges,68% of Total Billed Charges,598.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,440,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,416.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1155.82,100,,,Fee Schedule,100% of MO Medicaid Rate,1733.73,135,,,Fee Schedule,135% of CMS OPPS Rate,1178.94,102,,,Fee Schedule,102% MO Medicaid rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS rate,1178.94,102,,,Fee Schedule,102% of MO Medicaid rate,1155.82,100,,,Fee Schedule,100% of MO Medicaid rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,1155.82,100,,,Fee Schedule,100% of MO Medicaid Rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS Rate,300,1733.73,
NUC.MED. MYOCARD PERFUSION IMA,520381,CDM,340,RC,78464,HCPCS,Outpatient,,,2137,1495.9,,,,,,Other,Not Seperately Reimbusable,1453.16,68,,1162.53,Percent of Total Billed Charges,68% of Total Billed Charges,1453.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,1068.5,50,,117.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,1453.16,
NUC.MED. MYOCARD PERFUSION IMA,520382,CDM,340,RC,78452,HCPCS,Outpatient,,,3410,2387,,78.86,100,,,fee schedule,100% Aetna Market fee schedule,2318.8,68,,1855.04,Percent of Total Billed Charges,68% of Total Billed Charges,2318.8,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,1705,50,,138.8,Percent of Total Billed Charges,50% of Total Billed Charges,615.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1155.82,100,,,Fee Schedule,100% of MO Medicaid Rate,1733.73,135,,,Fee Schedule,135% of CMS OPPS Rate,1178.94,102,,,Fee Schedule,102% MO Medicaid rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS rate,1178.94,102,,,Fee Schedule,102% of MO Medicaid rate,1155.82,100,,,Fee Schedule,100% of MO Medicaid rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,1155.82,100,,,Fee Schedule,100% of MO Medicaid Rate,1284.25,100,,,Fee Schedule,100% of CMS OPPS Rate,300,2318.8,
NUC.MED. MYOCARD PERFUSION W/W,520384,CDM,340,RC,78478,HCPCS,Outpatient,,,1390,973,,,,,,Other,Not Seperately Reimbusable,945.2,68,,756.16,Percent of Total Billed Charges,68% of Total Billed Charges,945.2,68,,3459.52,Percent of Total Billed Charges,68% of Total Billed Charges,695,50,,186.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,945.2,
NUC.MED. MYOCARD PERFUSION W/E,520386,CDM,340,RC,78480,HCPCS,Outpatient,,,1390,973,,,,,,Other,Not Seperately Reimbusable,945.2,68,,756.16,Percent of Total Billed Charges,68% of Total Billed Charges,945.2,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,695,50,,200,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,945.2,
NUC.MED. KIDNEY IMAG.W/VAS FLO,520388,CDM,340,RC,78707,HCPCS,Outpatient,,,1430,1001,,45.61,100,,,fee schedule,100% Aetna Market fee schedule,972.4,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,972.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,715,50,,98.8,Percent of Total Billed Charges,50% of Total Billed Charges,294.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,659.94,135,,,Fee Schedule,135% of CMS OPPS Rate,448.77,102,,,Fee Schedule,102% MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS rate,448.77,102,,,Fee Schedule,102% of MO Medicaid rate,439.97,100,,,Fee Schedule,100% of MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,294.82,972.4,
NUC.MED. PARATHYROID IMAGING,520389,CDM,340,RC,78070,HCPCS,Outpatient,,,976,683.2,,38.55,100,,,fee schedule,100% Aetna Market fee schedule,663.68,68,,530.94,Percent of Total Billed Charges,68% of Total Billed Charges,663.68,68,,2098.82,Percent of Total Billed Charges,68% of Total Billed Charges,488,50,,117.2,Percent of Total Billed Charges,50% of Total Billed Charges,398.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,663.68,
NUC.MED. HEPA SYS IMAG GB KINE,520391,CDM,340,RC,78227,HCPCS,Outpatient,,,1280,896,,43.81,100,,,fee schedule,100% Aetna Market fee schedule,870.4,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,870.4,68,,2098.82,Percent of Total Billed Charges,68% of Total Billed Charges,640,50,,157.6,Percent of Total Billed Charges,50% of Total Billed Charges,612.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,659.94,135,,,Fee Schedule,135% of CMS OPPS Rate,448.77,102,,,Fee Schedule,102% MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS rate,448.77,102,,,Fee Schedule,102% of MO Medicaid rate,439.97,100,,,Fee Schedule,100% of MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,870.4,
BRAIN SCAN,520400,CDM,340,RC,78605,HCPCS,Outpatient,,,866,606.2,,25.94,100,,,fee schedule,100% Aetna Market fee schedule,588.88,68,,471.1,Percent of Total Billed Charges,68% of Total Billed Charges,588.88,68,,515.78,Percent of Total Billed Charges,68% of Total Billed Charges,433,50,,181.2,Percent of Total Billed Charges,50% of Total Billed Charges,276.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,659.94,135,,,Fee Schedule,135% of CMS OPPS Rate,448.77,102,,,Fee Schedule,102% MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS rate,448.77,102,,,Fee Schedule,102% of MO Medicaid rate,439.97,100,,,Fee Schedule,100% of MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,276.52,659.94,
BRAIN SCAN-CEREBRAL,520425,CDM,340,RC,78615,HCPCS,Outpatient,,,802,561.4,,,,,,Other,Not Seperately Reimbusable,545.36,68,,436.29,Percent of Total Billed Charges,68% of Total Billed Charges,545.36,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,401,50,,240,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,545.36,
BRAIN SCAN W/VAS.FLW,520450,CDM,340,RC,78606,HCPCS,Outpatient,,,2547,1782.9,,31.15,100,,,fee schedule,100% Aetna Market fee schedule,1731.96,68,,1385.57,Percent of Total Billed Charges,68% of Total Billed Charges,1731.96,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,1273.5,50,,104.4,Percent of Total Billed Charges,50% of Total Billed Charges,467.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,659.94,135,,,Fee Schedule,135% of CMS OPPS Rate,448.77,102,,,Fee Schedule,102% MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS rate,448.77,102,,,Fee Schedule,102% of MO Medicaid rate,439.97,100,,,Fee Schedule,100% of MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,1731.96,
NUC.MED. HEPA SYS IMAG W/GALLB,520491,CDM,340,RC,78226,HCPCS,Outpatient,,,1280,896,,36.07,100,,,fee schedule,100% Aetna Market fee schedule,870.4,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,870.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,640,50,,136,Percent of Total Billed Charges,50% of Total Billed Charges,450.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,870.4,
NUC.MED. GI BLOOD LOSS STUDY,520556,CDM,340,RC,78278,HCPCS,Outpatient,,,1089,762.3,,48.04,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,184,Percent of Total Billed Charges,50% of Total Billed Charges,468.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
MYOCARDIAL SCAN,520600,CDM,340,RC,78466,HCPCS,Outpatient,,,589,412.3,,34.97,100,,,fee schedule,100% Aetna Market fee schedule,400.52,68,,320.42,Percent of Total Billed Charges,68% of Total Billed Charges,400.52,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,294.5,50,,232,Percent of Total Billed Charges,50% of Total Billed Charges,232.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,232.48,503.57,
NUC.MED. KIDNEY IMAGING W/VAS,520700,CDM,340,RC,78701,HCPCS,Outpatient,,,1430,1001,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,972.4,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,972.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,715,50,,540,Percent of Total Billed Charges,50% of Total Billed Charges,318.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,972.4,
NUC.MED. KIDNEY IMAGING;W/FUNC,520705,CDM,340,RC,78707,HCPCS,Outpatient,,,695,486.5,,45.61,100,,,fee schedule,100% Aetna Market fee schedule,472.6,68,,378.08,Percent of Total Billed Charges,68% of Total Billed Charges,472.6,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,347.5,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,294.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,659.94,135,,,Fee Schedule,135% of CMS OPPS Rate,448.77,102,,,Fee Schedule,102% MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS rate,448.77,102,,,Fee Schedule,102% of MO Medicaid rate,439.97,100,,,Fee Schedule,100% of MO Medicaid rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,439.97,100,,,Fee Schedule,100% of MO Medicaid Rate,488.84,100,,,Fee Schedule,100% of CMS OPPS Rate,294.82,659.94,
NUC.MED. LIVER/SPLEEN IMAG;W/V,520800,CDM,340,RC,78216,HCPCS,Outpatient,,,1280,896,,27.03,100,,,fee schedule,100% Aetna Market fee schedule,870.4,68,,696.32,Percent of Total Billed Charges,68% of Total Billed Charges,870.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,640,50,,314.4,Percent of Total Billed Charges,50% of Total Billed Charges,175.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,175.94,870.4,
"NUC.MED. PULMONARY PERFUSION,P",520802,CDM,340,RC,78580,HCPCS,Outpatient,,,909,636.3,,36.07,100,,,fee schedule,100% Aetna Market fee schedule,618.12,68,,494.5,Percent of Total Billed Charges,68% of Total Billed Charges,618.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,454.5,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,313.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,618.12,
NUC.MED. PULMONARY VENTILATION,520804,CDM,340,RC,78593,HCPCS,Outpatient,,,909,636.3,,,,,,Other,Not Seperately Reimbusable,618.12,68,,494.5,Percent of Total Billed Charges,68% of Total Billed Charges,618.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,454.5,50,,45.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,618.12,
NUC.MED. PLANAR MYOCARDIAL,520820,CDM,340,RC,78461,HCPCS,Outpatient,,,2137,1495.9,,,,,,Other,Not Seperately Reimbusable,1453.16,68,,1162.53,Percent of Total Billed Charges,68% of Total Billed Charges,1453.16,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,1068.5,50,,140,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,1453.16,
LUNG SCAN PERFUSION,520850,CDM,340,RC,78580,HCPCS,Outpatient,,,909,636.3,,36.07,100,,,fee schedule,100% Aetna Market fee schedule,618.12,68,,494.5,Percent of Total Billed Charges,68% of Total Billed Charges,618.12,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,454.5,50,,220,Percent of Total Billed Charges,50% of Total Billed Charges,313.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,618.12,
SCHILLING TEST,520879,CDM,340,RC,78270,HCPCS,Outpatient,,,796,557.2,,,,,,Other,Not Seperately Reimbusable,541.28,68,,433.02,Percent of Total Billed Charges,68% of Total Billed Charges,541.28,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,398,50,,68.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,541.28,
SUL. COLLOID SCAN,520881,CDM,340,RC,79200,HCPCS,Outpatient,,,1543,1080.1,,54.17,100,,,fee schedule,100% Aetna Market fee schedule,1049.24,68,,839.39,Percent of Total Billed Charges,68% of Total Billed Charges,1049.24,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,771.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,90.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.51,100,,,Fee Schedule,100% of MO Medicaid Rate,303.75,135,,,Fee Schedule,135% of CMS OPPS Rate,206.56,102,,,Fee Schedule,102% MO Medicaid rate,225,100,,,Fee Schedule,100% of CMS OPPS rate,206.56,102,,,Fee Schedule,102% of MO Medicaid rate,202.51,100,,,Fee Schedule,100% of MO Medicaid rate,225,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,202.51,100,,,Fee Schedule,100% of MO Medicaid Rate,225,100,,,Fee Schedule,100% of CMS OPPS Rate,90.58,1049.24,
NUC.MED. TESTICULAR IMAGING W/,520890,CDM,340,RC,78761,HCPCS,Outpatient,,,1430,1001,,35.34,100,,,fee schedule,100% Aetna Market fee schedule,972.4,68,,777.92,Percent of Total Billed Charges,68% of Total Billed Charges,972.4,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,715,50,,156,Percent of Total Billed Charges,50% of Total Billed Charges,281.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,281.08,972.4,
TC SCAN-MECKELS DIV.,520893,CDM,340,RC,78290,HCPCS,Outpatient,,,1089,762.3,,32.92,100,,,fee schedule,100% Aetna Market fee schedule,740.52,68,,592.42,Percent of Total Billed Charges,68% of Total Billed Charges,740.52,68,,200.64,Percent of Total Billed Charges,68% of Total Billed Charges,544.5,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,462.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,740.52,
NUC.MED. THYROID SCAN,520900,CDM,340,RC,78013,HCPCS,Outpatient,,,641,448.7,,17.9,100,,,fee schedule,100% Aetna Market fee schedule,435.88,68,,348.7,Percent of Total Billed Charges,68% of Total Billed Charges,435.88,68,,200.64,Percent of Total Billed Charges,68% of Total Billed Charges,320.5,50,,156,Percent of Total Billed Charges,50% of Total Billed Charges,265.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,265.08,503.57,
NUC.MED. THYROID IMAGING W/UPT,520901,CDM,340,RC,78012,HCPCS,Outpatient,,,976,683.2,,9.11,100,,,fee schedule,100% Aetna Market fee schedule,663.68,68,,530.94,Percent of Total Billed Charges,68% of Total Billed Charges,663.68,68,,200.64,Percent of Total Billed Charges,68% of Total Billed Charges,488,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,124.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,503.57,135,,,Fee Schedule,135% of CMS OPPS Rate,342.43,102,,,Fee Schedule,102% MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS rate,342.43,102,,,Fee Schedule,102% of MO Medicaid rate,335.72,100,,,Fee Schedule,100% of MO Medicaid rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,335.72,100,,,Fee Schedule,100% of MO Medicaid Rate,373.02,100,,,Fee Schedule,100% of CMS OPPS Rate,124.32,663.68,
CT UPPER EXTREMITY W/CONTRAST,520483,CDM,340,RC,73201,HCPCS,Outpatient,,,1880,1316,,65.59,100,,,fee schedule,100% Aetna Market fee schedule,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,940,50,,752,Percent of Total Billed Charges,50% of Total Billed Charges,260.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,260.34,1278.4,
CT LOWER EXTREMITY W/CONTRAST,520485,CDM,340,RC,73701,HCPCS,Outpatient,,,912,638.4,,65.98,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,456,50,,364.8,Percent of Total Billed Charges,50% of Total Billed Charges,200.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,620.16,
CT BONE DENSITY,520488,CDM,340,RC,77078,HCPCS,Outpatient,,,319,223.3,,14.17,100,,,fee schedule,100% Aetna Market fee schedule,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,127.6,Percent of Total Billed Charges,50% of Total Billed Charges,157.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,110.94,135,,,Fee Schedule,135% of CMS OPPS Rate,75.44,102,,,Fee Schedule,102% MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS rate,75.44,102,,,Fee Schedule,102% of MO Medicaid rate,73.96,100,,,Fee Schedule,100% of MO Medicaid rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,73.96,100,,,Fee Schedule,100% of MO Medicaid Rate,82.18,100,,,Fee Schedule,100% of CMS OPPS Rate,73.96,300,
CT LOWER EXTREMITY W/WO CONTRA,520497,CDM,340,RC,73702,HCPCS,Outpatient,,,912,638.4,,69.55,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,456,50,,364.8,Percent of Total Billed Charges,50% of Total Billed Charges,246.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,620.16,
CT UPPER EXTREMITY W/WO CONTRA,520502,CDM,340,RC,73202,HCPCS,Outpatient,,,912,638.4,,69.55,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,456,50,,364.8,Percent of Total Billed Charges,50% of Total Billed Charges,340.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,620.16,
CT FOR NEEDLE BIOPSY,520504,CDM,340,RC,77012,HCPCS,Outpatient,,,1282,897.4,,83.75,100,,,fee schedule,100% Aetna Market fee schedule,871.76,68,,697.41,Percent of Total Billed Charges,68% of Total Billed Charges,871.76,68,,697.41,Percent of Total Billed Charges,68% of Total Billed Charges,641,50,,512.8,Percent of Total Billed Charges,50% of Total Billed Charges,121.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.3,871.76,
CT NECK W/O CONTRAST,520474,CDM,350,RC,70490,HCPCS,Outpatient,,,556,389.2,,73.2,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,160.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT NECK W/CONTRAST,520475,CDM,350,RC,70491,HCPCS,Outpatient,,,912,638.4,,78.88,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,213.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT THORAX W/O CONTRAST,520476,CDM,350,RC,71250,HCPCS,Outpatient,,,556,389.2,,61.51,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,147.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT THORAX W/CONTRAST,520477,CDM,350,RC,71260,HCPCS,Outpatient,,,912,638.4,,65.98,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,200.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT LUMBAR SPINE W/O CONTRAST,520478,CDM,350,RC,72131,HCPCS,Outpatient,,,556,389.2,,57.04,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,147.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT PELVIS W/O CONTRAST,520480,CDM,350,RC,72192,HCPCS,Outpatient,,,556,389.2,,61.93,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,146.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT PELVIS W/CONTRAST,520481,CDM,350,RC,72193,HCPCS,Outpatient,,,912,638.4,,65.98,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,310.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT UPPER EXTREMITY W/O CONTRAS,520482,CDM,350,RC,73200,HCPCS,Outpatient,,,556,389.2,,57.04,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,203.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT LOWER EXTREMITY W/O CONTRAS,520484,CDM,350,RC,73700,HCPCS,Outpatient,,,556,389.2,,57.04,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,147.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT ABDOMEN W/O CONTRAST,520486,CDM,350,RC,74150,HCPCS,Outpatient,,,556,389.2,,68.32,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,144.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT ABDOMEN W/CONTRAST,520487,CDM,350,RC,74160,HCPCS,Outpatient,,,912,638.4,,72.79,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,308.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT ORBIT W/O CONTRAST,520489,CDM,350,RC,70480,HCPCS,Outpatient,,,556,389.2,,73.2,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,176.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT ORBIT W/CONTRAST,520490,CDM,350,RC,70481,HCPCS,Outpatient,,,912,638.4,,63.96,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,227.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT ABDOMEN W/WO CONTRAST,520492,CDM,350,RC,74170,HCPCS,Outpatient,,,1000,700,,80.06,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,349.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
CT 0RBIT W/WO CONTRAST,520494,CDM,350,RC,70482,HCPCS,Outpatient,,,1000,700,,72.39,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,269.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
CT MAXILLOFACIAL AREA W/WO CON,520498,CDM,350,RC,70488,HCPCS,Outpatient,,,1000,700,,72.39,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,222.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
CT MAXILLOFACIAL AREA W/O CONT,520499,CDM,350,RC,70486,HCPCS,Outpatient,,,556,389.2,,48.56,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,156.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT MAXILLOFACIAL AREA W/CONTRA,520500,CDM,350,RC,70487,HCPCS,Outpatient,,,912,638.4,,63.96,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,177.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT NECK W/WO CONTRAST,520501,CDM,350,RC,70492,HCPCS,Outpatient,,,1000,700,,92.21,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,259.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
CT THORAX W/WO CONTRAST,520503,CDM,350,RC,71270,HCPCS,Outpatient,,,1000,700,,71.57,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,245.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
CT ABDOMEN & PELVIS W/O CONTRA,520505,CDM,350,RC,74176,HCPCS,Outpatient,,,1175,822.5,,99.11,100,,,fee schedule,100% Aetna Market fee schedule,799,68,,639.2,Percent of Total Billed Charges,68% of Total Billed Charges,799,68,,639.2,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,182.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,182.58,799,
CT ABDOMEN & PELVIS W/CONTRAST,520506,CDM,350,RC,74177,HCPCS,Outpatient,,,1880,1316,,103.97,100,,,fee schedule,100% Aetna Market fee schedule,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,388.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,1278.4,
CTA HEAD,520507,CDM,350,RC,70496,HCPCS,Outpatient,,,1200,840,,99.53,100,,,fee schedule,100% Aetna Market fee schedule,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,345.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,816,
CT ABDOMEN & PELVIS W/WO CONTR,520508,CDM,350,RC,74178,HCPCS,Outpatient,,,1880,1316,,114.15,100,,,fee schedule,100% Aetna Market fee schedule,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,438.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,1278.4,
CT CERVICAL SPINE W/O CONTRAST,520510,CDM,350,RC,72125,HCPCS,Outpatient,,,556,389.2,,57.04,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,148.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT CERVICAL SPINE W/CONTRAST,520514,CDM,350,RC,72126,HCPCS,Outpatient,,,1880,1316,,69.55,100,,,fee schedule,100% Aetna Market fee schedule,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,199.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,199.16,1278.4,
CT CERVICAL SPINE W/WO CONTRAS,520518,CDM,350,RC,72127,HCPCS,Outpatient,,,912,638.4,,72.75,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,246.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CTA NECK,520520,CDM,350,RC,70498,HCPCS,Outpatient,,,1200,840,,99.53,100,,,fee schedule,100% Aetna Market fee schedule,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,345.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,816,
CT THORACIC SPINE W/O CONTRAST,520522,CDM,350,RC,72128,HCPCS,Outpatient,,,556,389.2,,57.04,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,148.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CTA ABDOMINAL AORTA W/RUNOFFS,520523,CDM,350,RC,75635,HCPCS,Outpatient,,,1400,980,,134.44,100,,,fee schedule,100% Aetna Market fee schedule,952,68,,761.6,Percent of Total Billed Charges,68% of Total Billed Charges,952,68,,761.6,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,533.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,952,
CTA LOWER EXT,520524,CDM,350,RC,73706,HCPCS,Outpatient,,,1200,840,,106.88,100,,,fee schedule,100% Aetna Market fee schedule,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,816,68,,652.8,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,417.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,816,
CT PE PROTOCOL,520525,CDM,350,RC,71275,HCPCS,Outpatient,,,1175,822.5,,103.58,100,,,fee schedule,100% Aetna Market fee schedule,799,68,,639.2,Percent of Total Billed Charges,68% of Total Billed Charges,799,68,,639.2,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,349.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,799,
CT PELVIS W/WO CONTRAST,520526,CDM,350,RC,72194,HCPCS,Outpatient,,,1000,700,,69.55,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,347.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
INJECTION FOR BLADDER XRAY,520527,CDM,350,RC,51600,HCPCS,Outpatient,,,256,179.2,,38.99,100,,,fee schedule,100% Aetna Market fee schedule,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,82.14,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.14,650,
ANGIOGRAM RENAL ARTERIES W/WO,520530,CDM,350,RC,74175,HCPCS,Outpatient,,,1499,1049.3,,102.8,100,,,fee schedule,100% Aetna Market fee schedule,1019.32,68,,815.46,Percent of Total Billed Charges,68% of Total Billed Charges,1019.32,68,,815.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,393.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,1019.32,
CT ANGIOGRAPHY-PELVIS,520550,CDM,350,RC,72191,HCPCS,Outpatient,,,1499,1049.3,,102,100,,,fee schedule,100% Aetna Market fee schedule,1019.32,68,,815.46,Percent of Total Billed Charges,68% of Total Billed Charges,1019.32,68,,815.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,392.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,1019.32,
CT L-SPINE W/CONTRAST,520590,CDM,350,RC,72132,HCPCS,Outpatient,,,1880,1316,,69.55,100,,,fee schedule,100% Aetna Market fee schedule,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,1278.4,68,,1022.72,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,199.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,199.72,1278.4,
CT L-SPINE W/WO CONTRAST,520595,CDM,350,RC,72133,HCPCS,Outpatient,,,912,638.4,,72.75,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,246.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
EXTERNAL EAR XRAY,810425,CDM,350,RC,70480,HCPCS,Outpatient,,,858,600.6,,73.2,100,,,fee schedule,100% Aetna Market fee schedule,583.44,68,,466.75,Percent of Total Billed Charges,68% of Total Billed Charges,583.44,68,,466.75,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,176.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT BRAIN W/O CONTRAST,520472,CDM,351,RC,70450,HCPCS,Outpatient,,,556,389.2,,48.16,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,118.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,650,
CT BRAIN W/CONTRAST,520473,CDM,351,RC,70460,HCPCS,Outpatient,,,912,638.4,,64.36,100,,,fee schedule,100% Aetna Market fee schedule,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,68,,496.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,169.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,650,
CT BRAIN W/WO CONTRAST,520493,CDM,351,RC,70470,HCPCS,Outpatient,,,1000,700,,72.79,100,,,fee schedule,100% Aetna Market fee schedule,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,680,68,,544,Percent of Total Billed Charges,68% of Total Billed Charges,650,100,,,Case Rate,Pays based on per visit rate,203.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,224.33,135,,,Fee Schedule,135% of CMS OPPS Rate,152.55,102,,,Fee Schedule,102% MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS rate,152.55,102,,,Fee Schedule,102% of MO Medicaid rate,149.56,100,,,Fee Schedule,100% of MO Medicaid rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Case Rate,Pays based on per visit rate,149.56,100,,,Fee Schedule,100% of MO Medicaid Rate,166.17,100,,,Fee Schedule,100% of CMS OPPS Rate,149.56,680,
NON CONTACT LAYER,61250,CDM,360,RC,Y7509,HCPCS,Outpatient,,,5328,3729.6,,,,,,Other,Not Seperately Reimbusable,1290.5,100,,,Case Rate,Pays based on per visit rate,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,2664,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2664,
EXC FOOT/TOE TUM SC <1.5CM,55055,CDM,360,RC,,,Outpatient,,,2874,2011.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,61.41,Percent of Total Billed Charges,76% of Total Billed Charges,1437,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,1868.1,65,,1494.48,Percent of Total Billed Charges,65% of Total Billed Charges,2155.5,75,,1724.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,574.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,1724.4,60,,1379.52,Percent of Total Billed Charges,60% of Total Billed Charges,586.3,20.4,,469.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,586.3,20.4,,469.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,574.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,574.8,20,,459.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,574.8,2155.5,
CMPLX RPR SCALP ARM LG EA ADD,540108,CDM,360,RC,13122,HCPCS,Outpatient,,,556,389.2,,70.56,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,278,50,,465.6,Percent of Total Billed Charges,50% of Total Billed Charges,155.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.2,70,,311.36,Percent of Total Billed Charges,70% of Total Billed Charges,417,75,,333.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
MAJ.SUR.   1- 60 MIN,540350,CDM,360,RC,X4006,HCPCS,Outpatient,,,842,589.4,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,421,50,,79.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.4,70,,471.52,Percent of Total Billed Charges,70% of Total Billed Charges,631.5,75,,505.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,1444.4,
MAJ.SUR.  61- 90 MIN,540400,CDM,360,RC,X4006,HCPCS,Outpatient,,,1157,809.9,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,578.5,50,,946,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,809.9,70,,647.92,Percent of Total Billed Charges,70% of Total Billed Charges,867.75,75,,694.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,578.5,1444.4,
MAJ.SUR.  91-120 MIN,540450,CDM,360,RC,X4006,HCPCS,Outpatient,,,1418,992.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,709,50,,1022.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,992.6,70,,794.08,Percent of Total Billed Charges,70% of Total Billed Charges,1063.5,75,,850.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709,1444.4,
MAJ.SUR. 121-150 MIN,540500,CDM,360,RC,X4006,HCPCS,Outpatient,,,1733,1213.1,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,866.5,50,,773.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,866.5,1444.4,
MAJ.SUR. 151-180 MIN,540550,CDM,360,RC,X4006,HCPCS,Outpatient,,,2048,1433.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1024,50,,332,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1024,1444.4,
MAJ.SUR. 181-210 MIN,540600,CDM,360,RC,X4006,HCPCS,Outpatient,,,2573,1801.1,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1286.5,50,,773.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1444.4,
MAJ.SUR. 211-240 MIN,540650,CDM,360,RC,X4006,HCPCS,Outpatient,,,2888,2021.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1444,50,,1022.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1444.4,
MAJ.SUR. 241-270 MIN,540700,CDM,360,RC,X4006,HCPCS,Outpatient,,,3412,2388.4,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1706,50,,76,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1706,
MAJ.SUR. 271-300 MIN,540750,CDM,360,RC,X4006,HCPCS,Outpatient,,,3779,2645.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1889.5,50,,1022.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1889.5,
MAJ.SUR. 301-330 MIN,540800,CDM,360,RC,X4006,HCPCS,Outpatient,,,4094,2865.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2047,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2047,
MAJ.SUR. 331-360 MIN,540850,CDM,360,RC,X4006,HCPCS,Outpatient,,,4619,3233.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2309.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2309.5,
MAJ.SUR. 361-390 MIN,540900,CDM,360,RC,X4006,HCPCS,Outpatient,,,4724,3306.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,820.8,Percent of Total Billed Charges,76% of Total Billed Charges,2362,50,,773.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2362,
SPLT GRAFT TRUNK EA 100 SQ CM,540921,CDM,360,RC,15101,HCPCS,Outpatient,,,2251,1575.7,,96.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,237.12,Percent of Total Billed Charges,76% of Total Billed Charges,1125.5,50,,36.4,Percent of Total Billed Charges,50% of Total Billed Charges,207.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
EXC B9 LESION MRGN XCP SKTG T/,540922,CDM,360,RC,11402,HCPCS,Outpatient,,,1220,854,,98.92,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,610,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,214.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,854,70,,683.2,Percent of Total Billed Charges,70% of Total Billed Charges,915,75,,732,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,214.64,1444.4,
AMPUTATN FT TRANSMETATARSAL,540923,CDM,360,RC,28805,HCPCS,Outpatient,,,5474,3831.8,,649.12,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,1342.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
EXC TUM SFT TISS NECK ANT THRX,540925,CDM,360,RC,21552,HCPCS,Outpatient,,,4637,3245.9,,409.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,335.01,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,847.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3469.39,
CMPLX RPR FACE NCK AX GEN HND,540929,CDM,360,RC,13133,HCPCS,Outpatient,,,547,382.9,,107.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,273.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,235.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.9,70,,306.32,Percent of Total Billed Charges,70% of Total Billed Charges,410.25,75,,328.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
RPR I/HERN INIT BLOCK>5 YR,540931,CDM,360,RC,49507,HCPCS,Outpatient,,,6218,4352.6,,539.79,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,1119,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4224.16,
REPR UMB HERNIA>5 YRS INCAR ST,540932,CDM,360,RC,49587,HCPCS,Outpatient,,,6218,4352.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,3109,
MAJ.SUR. 391-420 MIN,540950,CDM,360,RC,X4006,HCPCS,Outpatient,,,5038,3526.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2519,50,,251.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2519,
MAJ.SUR. 421-575 MIN,540960,CDM,360,RC,X4006,HCPCS,Outpatient,,,5324,3726.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2662,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2662,
MAJ.SUR. 576-730 MIN,540965,CDM,360,RC,X4006,HCPCS,Outpatient,,,7381,5166.7,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3690.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,3690.5,
PENIS PLASTIC SURGERY,540972,CDM,360,RC,54360,HCPCS,Outpatient,,,6036,4225.2,,711.47,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,1364.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,4256.51,
INSRT MULTI CMPNT INFLAT PENL,540973,CDM,360,RC,54405,HCPCS,Outpatient,,,35144,24600.8,,797.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,1529.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24629.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1103,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1100,24629.28,
EXCISN OF HYDROCELE BILATERAL,540974,CDM,360,RC,55041,HCPCS,Outpatient,,,6218,4352.6,,505.74,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,968.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4224.16,
INSRT MESH PRSTH PELVC FLR DFE,540976,CDM,360,RC,57267,HCPCS,Outpatient,,,1364,954.8,,211.74,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,682,50,,192,Percent of Total Billed Charges,50% of Total Billed Charges,478.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,954.8,70,,763.84,Percent of Total Billed Charges,70% of Total Billed Charges,1023,75,,818.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
COLPOPEXY EXTRAPERITONEAL,540977,CDM,360,RC,57282,HCPCS,Outpatient,,,13406,9384.2,,589.78,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,141.66,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1319.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9226.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6834.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6834.33,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,6834.33,100,,,Fee Schedule,100% of CMS OPPS Rate,972,9226.35,
OSTECTOMY COMPLETE 1ST METATAR,540978,CDM,360,RC,28111,HCPCS,Outpatient,,,5474,3831.8,,292.78,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,67.2,Percent of Total Billed Charges,50% of Total Billed Charges,603.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
"SKIN GRFT SPLIT TRK,ARM,LEG 1S",540997,CDM,360,RC,15100,HCPCS,Outpatient,,,3245,2271.5,,614.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1337.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2226.59,
EXCIS TUM UPPER ARM ELBOW IM,540998,CDM,360,RC,24076,HCPCS,Outpatient,,,4637,3245.9,,498.93,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1033.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3469.39,
"AMPUTATN,FT;MIDTARSAL",540999,CDM,360,RC,28800,HCPCS,Outpatient,,,2734,1913.8,,483.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1367,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,998.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2734,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2734,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2734,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2734,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,695,2734,
EXCIS OF CYST FIBROADENOMA 1+L,541003,CDM,360,RC,19120,HCPCS,Outpatient,,,6058,4240.6,,360.58,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,3029,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,790.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4654.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3447.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3447.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3447.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4654.03,
ALVEOLOPLSTY EA QUADRNT SPECIF,541004,CDM,360,RC,41874,HCPCS,Outpatient,,,5238,3666.6,,221.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,2619,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,452.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3931.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,452.38,3931.06,
UNLISTED PROC DENTOALVEOLAR ST,541005,CDM,360,RC,41899,HCPCS,Outpatient,,,407,284.9,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,203.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.9,70,,227.92,Percent of Total Billed Charges,70% of Total Billed Charges,305.25,75,,244.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
CHOLECYSTECTOMY,541008,CDM,360,RC,47600,HCPCS,Outpatient,,,3483,2438.1,,981.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1741.5,50,,94,Percent of Total Billed Charges,50% of Total Billed Charges,2037.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3483,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,3483,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3483,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3483,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,3483,
CYSTO W/FULG AND OR RESECT BLA,541009,CDM,360,RC,52235,HCPCS,Outpatient,,,9420,6594,,253.72,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,4710,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,542.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,542.86,4710,
TRANSURETHRAL RESECT BLADDER N,541010,CDM,360,RC,52500,HCPCS,Outpatient,,,6036,4225.2,,435.84,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,931.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
EPIDIDYMECTOMY UNILATERAL,541011,CDM,360,RC,54860,HCPCS,Outpatient,,,3543,2480.1,,413.85,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,78.4,Percent of Total Billed Charges,50% of Total Billed Charges,792.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
ADJ TIS TRN FORE 10 CM,541018,CDM,360,RC,14040,HCPCS,Outpatient,,,3245,2271.5,,530.51,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,418,Percent of Total Billed Charges,50% of Total Billed Charges,1160.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2226.59,
EXCIS TUM SFT TISS UPPR ARM SU,541020,CDM,360,RC,24071,HCPCS,Outpatient,,,4637,3245.9,,371.69,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,767.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3469.39,
AMPUTATION OF FINGER/THUMB,541022,CDM,360,RC,26952,HCPCS,Outpatient,,,5474,3831.8,,633.84,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,85.6,Percent of Total Billed Charges,50% of Total Billed Charges,1259.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3952.1,
EXCSN GANGLION WRIST PRIMARY,541023,CDM,360,RC,25111,HCPCS,Outpatient,,,2710,1897,,296.62,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1355,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,612.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1962.35,
REMV SLF CNTAIND PENIL PRSTHS,541028,CDM,360,RC,54415,HCPCS,Outpatient,,,6036,4225.2,,524.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1006.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4256.51,
EXC LES TEN OR JNT HND OR FIN,541031,CDM,360,RC,26160,HCPCS,Outpatient,,,2710,1897,,288.51,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,122.82,Percent of Total Billed Charges,76% of Total Billed Charges,1355,50,,118,Percent of Total Billed Charges,50% of Total Billed Charges,595.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1962.35,
REPR INIT INCIS VENT HERNIA RE,541032,CDM,360,RC,49560,HCPCS,Outpatient,,,6218,4352.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,124.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,3109,
MESH IMPLANTATN OF VENTRAL HER,541033,CDM,360,RC,49568,HCPCS,Outpatient,,,1885,1319.5,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,942.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,1444.4,
VASECTOMY,541034,CDM,360,RC,55250,HCPCS,Outpatient,,,1143,800.1,,224.91,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,571.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,431,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.1,70,,640.08,Percent of Total Billed Charges,70% of Total Billed Charges,857.25,75,,685.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,431,2486.9,
UNLSTD LAPAROSCOPIC PROC LIVER,541036,CDM,360,RC,47379,HCPCS,Outpatient,,,9666,6766.2,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4833,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,972,7045.01,
RMVL REVSN SLING STRESS INCONT,541038,CDM,360,RC,57287,HCPCS,Outpatient,,,4996,3497.2,,630.93,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2498,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,1399.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3817.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,695,3817.21,
LAPAROSCOPIC CHOLECYSTECTOMY,541042,CDM,360,RC,47562,HCPCS,Outpatient,,,9666,6766.2,,606.81,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4833,50,,47.2,Percent of Total Billed Charges,50% of Total Billed Charges,1257.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,7045.01,
REPR ABDOMINAL WALL,541043,CDM,360,RC,49900,HCPCS,Outpatient,,,2673,1871.1,,752.45,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,1336.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1560.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2673,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2673,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2673,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2673,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,2673,
SLING OPRATION CORRJ MALE URIN,541044,CDM,360,RC,53440,HCPCS,Outpatient,,,2428,1699.6,,668.25,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,1214,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1424.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15673.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1098,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1098,15673.49,
POSTR COLPORRHAPHY RPR RCTCEL,541046,CDM,360,RC,57250,HCPCS,Outpatient,,,8542,5979.4,,524.01,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4271,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,1170.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,6073.02,
"EXCIS SFT TUM BACK,FLANK SUBQ",541055,CDM,360,RC,21931,HCPCS,Outpatient,,,2745,1921.5,,430.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,891.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
CLTX ULNAR FX PROXIMAL END,541056,CDM,360,RC,24675,HCPCS,Outpatient,,,2710,1897,,387.68,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,31.62,Percent of Total Billed Charges,76% of Total Billed Charges,1355,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,795.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1962.35,
REAMPUTATN OF THIGH THRU FEMUR,541057,CDM,360,RC,27596,HCPCS,Outpatient,,,2318,1622.6,,652.45,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,382.43,Percent of Total Billed Charges,76% of Total Billed Charges,1159,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,1346.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2318,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2318,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2318,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2318,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,941,2318,
INSRTN PENL PROSTHES NON INFLA,541059,CDM,360,RC,54400,HCPCS,Outpatient,,,35144,24600.8,,525.74,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,30.8,Percent of Total Billed Charges,50% of Total Billed Charges,1007.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,15673.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1098,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,11609.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1007.44,15673.49,
REPAIR CORPOREAL TEAR,541060,CDM,360,RC,54437,HCPCS,Outpatient,,,6036,4225.2,,668.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,1283,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
DESTR LES PENIS ELECTRO SIMP,541061,CDM,360,RC,54055,HCPCS,Outpatient,,,5248,3673.6,,92.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2624,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,178.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,178.72,2624,
EXC LES TENDON SHEATH FT,541071,CDM,360,RC,28090,HCPCS,Outpatient,,,2710,1897,,279.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1355,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,581.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1962.35,
REMOVAL OF FOREIGN BODY FT DEE,541072,CDM,360,RC,28192,HCPCS,Outpatient,,,2745,1921.5,,282.27,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,102.14,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,584.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1979.55,
EXC SOFT TIS TUM UPARM ELBOW,541073,CDM,360,RC,25075,HCPCS,Outpatient,,,2745,1921.5,,288.45,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,359.94,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,47.2,Percent of Total Billed Charges,50% of Total Billed Charges,595.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1979.55,
EXCISN OF HYDRPCELE UNILATERAL,541076,CDM,360,RC,55040,HCPCS,Outpatient,,,6218,4352.6,,334.49,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,640.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,640.4,4224.16,
RPR ENTEROCELE VAG APPRCH SEP,541077,CDM,360,RC,57268,HCPCS,Outpatient,,,8542,5979.4,,430.89,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1427.58,Percent of Total Billed Charges,76% of Total Billed Charges,4271,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,957,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,563,6073.02,
DESTRUCTION LESIONS VULVA SIMP,541086,CDM,360,RC,56501,HCPCS,Outpatient,,,5248,3673.6,,112.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2624,50,,533.6,Percent of Total Billed Charges,50% of Total Billed Charges,248.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,248.28,2624,
TRURL RESCJ RESID REGROW OBST,541087,CDM,360,RC,52630,HCPCS,Outpatient,,,1305,913.5,,359.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,652.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,913.5,70,,730.8,Percent of Total Billed Charges,70% of Total Billed Charges,978.75,75,,783,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,652.5,6317.76,
DIRECT LARYNGOSCOPE W/VC INJ,541133,CDM,360,RC,31570,HCPCS,Outpatient,,,1118,782.6,,237.04,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,559,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,431.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.6,70,,626.08,Percent of Total Billed Charges,70% of Total Billed Charges,838.5,75,,670.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4572.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS Rate,431.48,4572.35,
MINOR SURGERY,541145,CDM,360,RC,X4006,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,70,,89.04,Percent of Total Billed Charges,70% of Total Billed Charges,119.25,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,1444.4,
MIN.SUR.   1- 60 MIN,541150,CDM,360,RC,X4006,HCPCS,Outpatient,,,842,589.4,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,421,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,589.4,70,,471.52,Percent of Total Billed Charges,70% of Total Billed Charges,631.5,75,,505.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,421,1444.4,
MIN.SUR.  61- 90 MIN,541200,CDM,360,RC,X4006,HCPCS,Outpatient,,,1157,809.9,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,578.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,809.9,70,,647.92,Percent of Total Billed Charges,70% of Total Billed Charges,867.75,75,,694.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,578.5,1444.4,
MIN.SUR.  91-120 MIN,541250,CDM,360,RC,X4006,HCPCS,Outpatient,,,1261,882.7,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,630.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,882.7,70,,706.16,Percent of Total Billed Charges,70% of Total Billed Charges,945.75,75,,756.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,630.5,1444.4,
MIN.SUR. 121-150 MIN,541300,CDM,360,RC,X4006,HCPCS,Outpatient,,,1523,1066.1,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,761.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1066.1,70,,852.88,Percent of Total Billed Charges,70% of Total Billed Charges,1142.25,75,,913.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,761.5,1444.4,
MIN.SUR. 151-180 MIN,541350,CDM,360,RC,X4006,HCPCS,Outpatient,,,1839,1287.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,919.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,919.5,1444.4,
MIN.SUR. 181-210 MIN,541400,CDM,360,RC,X4006,HCPCS,Outpatient,,,2205,1543.5,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,1102.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1444.4,
MIN.SUR. 211-240 MIN,541450,CDM,360,RC,X4006,HCPCS,Outpatient,,,2519,1763.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1259.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1444.4,
MIN.SUR. 241-270 MIN,541500,CDM,360,RC,X4006,HCPCS,Outpatient,,,2834,1983.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,1417,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1444.4,
MIN.SUR. 271-300 MIN,541550,CDM,360,RC,X4006,HCPCS,Outpatient,,,3150,2205,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1575,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1575,
MIN.SUR. 301-330 MIN,541600,CDM,360,RC,X4006,HCPCS,Outpatient,,,3464,2424.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,142.88,Percent of Total Billed Charges,76% of Total Billed Charges,1732,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1732,
MIN.SUR. 331-360 MIN,541650,CDM,360,RC,X4006,HCPCS,Outpatient,,,3779,2645.3,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1889.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,1889.5,
MIN.SUR. 361-390 MIN,541700,CDM,360,RC,X4006,HCPCS,Outpatient,,,4094,2865.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,2047,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2047,
MIN.SUR. 391-420 MIN,541750,CDM,360,RC,X4006,HCPCS,Outpatient,,,4408,3085.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,119.17,Percent of Total Billed Charges,76% of Total Billed Charges,2204,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,2204,
OR FEE-MID AMERICAN TRANSPLANT,541760,CDM,360,RC,,,Outpatient,,,736,515.2,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,368,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,478.4,65,,382.72,Percent of Total Billed Charges,65% of Total Billed Charges,552,75,,441.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,515.2,70,,412.16,Percent of Total Billed Charges,70% of Total Billed Charges,552,75,,441.6,Percent of Total Billed Charges,75% of Total Billed Charges,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,441.6,60,,353.28,Percent of Total Billed Charges,60% of Total Billed Charges,150.14,20.4,,120.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,150.14,20.4,,120.11,Percent of Total Billed Charges,20.4% of Total Billed Charges,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.2,20,,117.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,147.2,1444.4,
ORCHIECTOMY DIMP WO W TESTIC P,541763,CDM,360,RC,54520,HCPCS,Outpatient,,,6036,4225.2,,323.97,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,620.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,620.84,4256.51,
COMBINED ANTEROPOSTERIOR COLPO,541764,CDM,360,RC,57260,HCPCS,Outpatient,,,8542,5979.4,,662.06,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,4271,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1483.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,6073.02,
EXSIC SPERMATOCELE WO W EPIDID,550198,CDM,360,RC,54840,HCPCS,Outpatient,,,3543,2480.1,,318.25,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,609.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,2486.9,
HEMORRHOIDECTOMY INT AND EXT>2,550223,CDM,360,RC,46260,HCPCS,Outpatient,,,4688,3281.6,,443.76,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,811.07,Percent of Total Billed Charges,76% of Total Billed Charges,2344,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,906,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3428.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3428.24,
REM MULTI COMP PENILE,550284,CDM,360,RC,54406,HCPCS,Outpatient,,,9420,6594,,721.46,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,4710,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,1384.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4710,
REVISE VAG GRAFT VIA VAGINA,550294,CDM,360,RC,57295,HCPCS,Outpatient,,,8039,5627.3,,426.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4019.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,949.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3817.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4019.5,
REVISION OF PENIS,550297,CDM,360,RC,54304,HCPCS,Outpatient,,,2397,1677.9,,738.09,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,129.5,Percent of Total Billed Charges,76% of Total Billed Charges,1198.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1414.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,4256.51,
RAD RESCT TUM SFT TISS UP-ARM/,550361,CDM,360,RC,24077,HCPCS,Outpatient,,,4637,3245.9,,943.12,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,1946.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3469.39,
REPR INIT ING HERNIA > 5YRS,550365,CDM,360,RC,49505,HCPCS,Outpatient,,,6218,4352.6,,480.64,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,994.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4224.16,
EXCIS HYDROCEL SPERMATIC CORD,550366,CDM,360,RC,55500,HCPCS,Outpatient,,,6036,4225.2,,389.28,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,740.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4256.51,
FULL THCK ARM LEG 20 SQ CM,550370,CDM,360,RC,15220,HCPCS,Outpatient,,,3245,2271.5,,519.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,1133.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2226.59,
RMV RPLC CMPNT INFLATBLE PENL,550374,CDM,360,RC,54410,HCPCS,Outpatient,,,35144,24600.8,,851.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,1632.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,24629.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1103,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,18243.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1100,24629.28,
RMVL/REVJ SLING MALE URINARY I,550376,CDM,360,RC,53442,HCPCS,Outpatient,,,8828,6179.6,,696.83,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,88.77,Percent of Total Billed Charges,76% of Total Billed Charges,4414,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,1484.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,695,6317.76,
I & D VULVA PERINEAL ABS,550378,CDM,360,RC,56405,HCPCS,Outpatient,,,541,378.7,,107.76,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,311.9,Percent of Total Billed Charges,76% of Total Billed Charges,270.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,378.7,70,,302.96,Percent of Total Billed Charges,70% of Total Billed Charges,405.75,75,,324.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
EXC B9 SCLP NK HND FT GN 1.1-2,550381,CDM,360,RC,11422,HCPCS,Outpatient,,,1271,889.7,,115.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,635.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,251.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,889.7,70,,711.76,Percent of Total Billed Charges,70% of Total Billed Charges,953.25,75,,762.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,251.84,1979.55,
REPAIR INTRMDIATE N/H/F/XTRNL,550383,CDM,360,RC,12041,HCPCS,Outpatient,,,1059,741.3,,122.93,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,529.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,270.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.3,70,,593.04,Percent of Total Billed Charges,70% of Total Billed Charges,794.25,75,,635.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
LARYNGOSCOPY DIRECT W BX,550385,CDM,360,RC,31535,HCPCS,Outpatient,,,9491,6643.7,,194.87,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,4745.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,355.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4572.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3386.93,100,,,Fee Schedule,100% of CMS OPPS Rate,355.72,4745.5,
CHOLECYSTECTOMY W/CHOLANGIOGRA,550430,CDM,360,RC,47605,HCPCS,Outpatient,,,3674,2571.8,,1035.51,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1837,50,,58.8,Percent of Total Billed Charges,50% of Total Billed Charges,2145.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3674,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,3674,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3674,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3674,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,3674,
EXC F/E/E/N/L MAL MRG 1.1 CM T,550491,CDM,360,RC,11642,HCPCS,Outpatient,,,1260,882,,155,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,630,50,,96.4,Percent of Total Billed Charges,50% of Total Billed Charges,338.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,882,70,,705.6,Percent of Total Billed Charges,70% of Total Billed Charges,945,75,,756,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,338.86,1444.4,
INCIS EXTRAPARENCHYMAL LESN TE,550496,CDM,360,RC,54512,HCPCS,Outpatient,,,6036,4225.2,,530.19,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1019.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
REPR UMB HERNIA > 5 YRS RED,550497,CDM,360,RC,49585,HCPCS,Outpatient,,,6218,4352.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,3109,
MESH IMPLANTATN OF VENTRAL HER,550498,CDM,360,RC,49568,HCPCS,Outpatient,,,1884,1318.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,644.48,Percent of Total Billed Charges,76% of Total Billed Charges,942,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,1444.4,
REPR INITIAL VENTRAL HERNIA IN,550499,CDM,360,RC,49561,HCPCS,Outpatient,,,6218,4352.6,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,3109,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,3109,
CYSTO IMPLANT 1-3 MEDICARE,550534,CDM,360,RC,,,Outpatient,,,4505,3153.5,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,89.38,Percent of Total Billed Charges,76% of Total Billed Charges,2252.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,2928.25,65,,2342.6,Percent of Total Billed Charges,65% of Total Billed Charges,3378.75,75,,2703,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,901,20,,720.8,Percent of Total Billed Charges,20% of Total Billed Charges,2703,60,,2162.4,Percent of Total Billed Charges,60% of Total Billed Charges,919.02,20.4,,735.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,919.02,20.4,,735.22,Percent of Total Billed Charges,20.4% of Total Billed Charges,901,20,,720.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,901,20,,720.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,901,3378.75,
CYSTO IMPLANT 4 OR MORE MEDICA,550535,CDM,360,RC,,,Outpatient,,,8462,5923.4,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,5500.3,65,,4400.24,Percent of Total Billed Charges,65% of Total Billed Charges,6346.5,75,,5077.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,1692.4,20,,1353.92,Percent of Total Billed Charges,20% of Total Billed Charges,5077.2,60,,4061.76,Percent of Total Billed Charges,60% of Total Billed Charges,1726.25,20.4,,1381,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1726.25,20.4,,1381,Percent of Total Billed Charges,20.4% of Total Billed Charges,1692.4,20,,1353.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1692.4,20,,1353.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1100,6346.5,
EXC TUM SFT TISS FT TOE SUBQ>=,550572,CDM,360,RC,28039,HCPCS,Outpatient,,,4637,3245.9,,316.16,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,640.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3469.39,
BIOPSY OF LIVER WEDGE,550574,CDM,360,RC,47100,HCPCS,Outpatient,,,2764,1934.8,,779.43,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,1382,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,1609.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2764,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2764,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2764,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2764,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,563,2764,
EXCIS TUM THIGH KNEE SUBCU,550577,CDM,360,RC,27327,HCPCS,Outpatient,,,2745,1921.5,,287.58,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,73.57,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,593.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
LAPAROSCOPIC CHOLECYSTECTOMY,550600,CDM,360,RC,47563,HCPCS,Outpatient,,,9666,6766.2,,660.33,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,4833,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,1367.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,7045.01,
CYSTOURETHRSCPY W LITHOTRIPSY,550604,CDM,360,RC,52353,HCPCS,Outpatient,,,8462,5923.4,,345.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,737.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,737.38,6317.76,
TRANSURETHRAL RESECT PROSTATE,550605,CDM,360,RC,52601,HCPCS,Outpatient,,,8462,5923.4,,646.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,1378.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,6317.76,
DESTR LES VULVA EXT,550607,CDM,360,RC,56515,HCPCS,Outpatient,,,3245,2271.5,,180.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,400.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400.44,2226.59,
ANT COLPORRHAPHY RPR CYSTCEL W,550608,CDM,360,RC,57240,HCPCS,Outpatient,,,8542,5979.4,,520.88,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,4271,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,1165.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,695,6073.02,
SLING OPERATN FOR STRESS INCON,550609,CDM,360,RC,57288,HCPCS,Outpatient,,,8542,5979.4,,630.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,4271,50,,416.4,Percent of Total Billed Charges,50% of Total Billed Charges,1410.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,972,6073.02,
INCIS ISCHIO ABSCESS,550614,CDM,360,RC,46040,HCPCS,Outpatient,,,3177,2223.9,,390.34,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,1588.5,50,,1098,Percent of Total Billed Charges,50% of Total Billed Charges,797.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1588.5,
CYSTOURETHRO W/INITIAL IMPLANT,550616,CDM,360,RC,52441,HCPCS,Outpatient,,,4505,3153.5,,184.81,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2252.5,50,,854.4,Percent of Total Billed Charges,50% of Total Billed Charges,394.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,2252.5,
LATE CLOSURE OF WOUND,550621,CDM,360,RC,13160,HCPCS,Outpatient,,,3245,2271.5,,686.42,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,1495.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2226.59,
AMPUTATN THIGH THRU FEMUR ANY,550628,CDM,360,RC,27590,HCPCS,Outpatient,,,3696,2587.2,,719.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,1848,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1491.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3696,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,3696,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3696,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1098,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3696,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1098,3696,
AMPUTATN LEG AT THIGH,550629,CDM,360,RC,27950,HCPCS,Outpatient,,,3186,2230.2,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1593,50,,1180.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,1593,
AMPUTATN LEG AT THIGH,550630,CDM,360,RC,27590,HCPCS,Outpatient,,,13790,9653,,719.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,1491.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,13790,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,13790,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13790,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1098,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,13790,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1098,13790,
FASCIOTOMY FT AND/OR TOE,550631,CDM,360,RC,28008,HCPCS,Outpatient,,,5474,3831.8,,267.84,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,132,Percent of Total Billed Charges,50% of Total Billed Charges,555.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,555.76,3952.1,
PRTL EXCIS BONEFT NOT TALUS OR,550633,CDM,360,RC,28122,HCPCS,Outpatient,,,5474,3831.8,,398.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,43.17,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,829.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
PARTL EXCIS BONE PHALANX OF TO,550634,CDM,360,RC,28124,HCPCS,Outpatient,,,5474,3831.8,,302.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,630.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
HALLUX VALGUS CORRECTN,550635,CDM,360,RC,28292,HCPCS,Outpatient,,,5474,3831.8,,437.25,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,917.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,695,3952.1,
SESAMOIDECTOMY 1ST TOE,550636,CDM,360,RC,28315,HCPCS,Outpatient,,,5474,3831.8,,297.46,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,78.43,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,112.8,Percent of Total Billed Charges,50% of Total Billed Charges,615.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
VASECTOMY,550639,CDM,360,RC,55250,HCPCS,Outpatient,,,1143,800.1,,224.91,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,571.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,431,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,800.1,70,,640.08,Percent of Total Billed Charges,70% of Total Billed Charges,857.25,75,,685.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,431,2486.9,
EXCIS TUM SFT TISS NECK THOR,550646,CDM,360,RC,21555,HCPCS,Outpatient,,,5121,3584.7,,279.95,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,2560.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,577.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2560.5,
INSERT TUN CENT CATH VEN DEVIC,550648,CDM,360,RC,36561,HCPCS,Outpatient,,,5542,3879.4,,336.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,49.86,Percent of Total Billed Charges,76% of Total Billed Charges,2771,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3891.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,622.7,3891.84,
REPAIR STOMACH OPENING,550650,CDM,360,RC,43870,HCPCS,Outpatient,,,9242,6469.4,,652.02,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,4621,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1348.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4676.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3463.73,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3463.73,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3463.73,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4676.04,
URETHROMETOPLSTY W/PRTL EXC DS,550652,CDM,360,RC,53460,HCPCS,Outpatient,,,9229,6460.3,,406.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,4614.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,866.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4614.5,
EXC FOREARM LES SC 3 CM/>,550654,CDM,360,RC,25071,HCPCS,Outpatient,,,1355,948.5,,388.13,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,677.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,803.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,948.5,70,,758.8,Percent of Total Billed Charges,70% of Total Billed Charges,1016.25,75,,813,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
RPR AA HRN 1ST < 3 CM RDC,550656,CDM,360,RC,49591,HCPCS,Outpatient,,,1085,759.5,,308.22,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,542.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,653.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,759.5,70,,607.6,Percent of Total Billed Charges,70% of Total Billed Charges,813.75,75,,651,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,542.5,4224.16,
REMOVE DRUG IMPLANT DEVICE,550890,CDM,360,RC,11982,HCPCS,Outpatient,,,355,248.5,,63.97,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,177.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,139.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.5,70,,198.8,Percent of Total Billed Charges,70% of Total Billed Charges,266.25,75,,213,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
EXC FACE-MM B9+MARG 0.6-1 CM,550892,CDM,360,RC,11441,HCPCS,Outpatient,,,555,388.5,,113.07,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,277.5,50,,125.6,Percent of Total Billed Charges,50% of Total Billed Charges,246.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.5,70,,310.8,Percent of Total Billed Charges,70% of Total Billed Charges,416.25,75,,333,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,246.36,1444.4,
INC&RMVL FB SUBQ TISS SMPL,550895,CDM,360,RC,10120,HCPCS,Outpatient,,,484,338.8,,88.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,242,50,,37.6,Percent of Total Billed Charges,50% of Total Billed Charges,195.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.8,70,,271.04,Percent of Total Billed Charges,70% of Total Billed Charges,363,75,,290.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
CHANGE OF BLADDER TUBE,550897,CDM,360,RC,51705,HCPCS,Outpatient,,,310,217,,45.48,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,155,50,,76.8,Percent of Total Billed Charges,50% of Total Billed Charges,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217,70,,173.6,Percent of Total Billed Charges,70% of Total Billed Charges,232.5,75,,186,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,97.34,1444.4,
EXC SHOULDER TUM DEEP < 5 CM,550899,CDM,360,RC,23076,HCPCS,Outpatient,,,1612,1128.4,,497.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,806,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1026.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3469.39,
EXC FACE TUM DEEP < 2 CM,550904,CDM,360,RC,21013,HCPCS,Outpatient,,,1711,1197.7,,365.58,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,50.46,Percent of Total Billed Charges,76% of Total Billed Charges,855.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,754.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,1979.55,
REVISION OF PENIS,550906,CDM,360,RC,54300,HCPCS,Outpatient,,,2072,1450.4,,638.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1036,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,1220.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,4256.51,
EXC HIP/PELVIS LES SC < 3 CM,550908,CDM,360,RC,27047,HCPCS,Outpatient,,,1589,1112.3,,329.99,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,794.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,684.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1191.75,75,,953.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3469.39,
NASAL/OROGASTRIC W/TUBE PLMT,550909,CDM,360,RC,43752,HCPCS,Outpatient,,,127,88.9,,36.72,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,63.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,75.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.9,70,,71.12,Percent of Total Billed Charges,70% of Total Billed Charges,95.25,75,,76.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,63.5,1444.4,
EXC TR-EXT MAL+MARG 1.1-2CM,550910,CDM,360,RC,11602,HCPCS,Outpatient,,,779,545.3,,137.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,389.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,299.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,545.3,70,,436.24,Percent of Total Billed Charges,70% of Total Billed Charges,584.25,75,,467.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
INTMD RPR S/A/T/EXT 2.5 CM/<,550912,CDM,360,RC,12031,HCPCS,Outpatient,,,833,583.1,,128.8,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,416.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,280.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,583.1,70,,466.48,Percent of Total Billed Charges,70% of Total Billed Charges,624.75,75,,499.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PARTIAL REMOVAL OF PENIS,550914,CDM,360,RC,54120,HCPCS,Outpatient,,,2033,1423.1,,624.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,193.95,Percent of Total Billed Charges,76% of Total Billed Charges,1016.5,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,1197.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4256.51,
EXCISION OF SCROTUM,551505,CDM,360,RC,55150,HCPCS,Outpatient,,,2400,1680,,488.91,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,138.62,Percent of Total Billed Charges,76% of Total Billed Charges,1200,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,932.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
PARTL REMOVAL OF FT BONE,893389,CDM,360,RC,28288,HCPCS,Outpatient,,,5474,3831.8,,394.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,817,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
CRPRA CVRNOSE/SPNGSM SHUNT,893394,CDM,360,RC,54430,HCPCS,Outpatient,,,2915,2040.5,,630.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1457.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,1208.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2915,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2915,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2915,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2915,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,366,2915,
CYSTOURETHRO EACH ADDITIONAL I,893401,CDM,360,RC,52442,HCPCS,Outpatient,,,2800,1960,,44.46,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1400,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,95.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.6,1444.4,
TRANSURETH RESECT BLADDER NECK,893411,CDM,360,RC,52640,HCPCS,Outpatient,,,9420,6594,,284.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4710,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,606.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4710,
APPENDECTOMY,893415,CDM,360,RC,44950,HCPCS,Outpatient,,,9748,6823.6,,589.57,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,171.46,Percent of Total Billed Charges,76% of Total Billed Charges,4874,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1224.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9237.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6842.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6842.51,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,6842.51,100,,,Fee Schedule,100% of CMS OPPS Rate,695,9237.37,
URETHROLYSIS TRANSVAG W/ SCOPE,893418,CDM,360,RC,53500,HCPCS,Outpatient,,,94200,65940,,666.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,1418.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9622.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,9484.42,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9484.42,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,9484.42,100,,,Fee Schedule,100% of CMS OPPS Rate,695,9622.37,
PARTIAL REMOVAL OF TOE,893422,CDM,360,RC,28126,HCPCS,Outpatient,,,8677,6073.9,,224.69,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,4338.5,50,,129.6,Percent of Total Billed Charges,50% of Total Billed Charges,472.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,4338.5,
EGD BALLOON DILATION <30MM,893424,CDM,360,RC,43249,HCPCS,Outpatient,,,4976,3483.2,,139.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,2488,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,287.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,287.28,2488,
COLNSC FLEXIBLE W CONTROL BLEE,893426,CDM,360,RC,45382,HCPCS,Outpatient,,,3177,2223.9,,235.46,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,1588.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,483.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,483.72,1588.5,
HEMORRHOID NTRNL XTERNL 1 COLU,893428,CDM,360,RC,46257,HCPCS,Outpatient,,,7485,5239.5,,381.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3742.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,779.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3428.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3742.5,
TRURL RESJ RESIDUAL/REGROWTH O,893430,CDM,360,RC,52630,HCPCS,Outpatient,,,13518,9462.6,,359.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,207.6,Percent of Total Billed Charges,50% of Total Billed Charges,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,765.22,6317.76,
BIOPSY OF URETHRA,893432,CDM,360,RC,53200,HCPCS,Outpatient,,,5486,3840.2,,125.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2743,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,268.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,268.88,2743,
DESTRJN LES PENIS SURG EXC SIM,893434,CDM,360,RC,54060,HCPCS,Outpatient,,,5248,3673.6,,128.95,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2624,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,247.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.44,2624,
LARYNGOSCOPY W/WO TRACHEOSCOPY,893520,CDM,360,RC,31515,HCPCS,Outpatient,,,3455,2418.5,,115.35,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1727.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,208.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,498.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,369.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,369.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,369.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1727.5,
CYSTOSCOPY CHEMODENERVATION BL,893522,CDM,360,RC,52287,HCPCS,Outpatient,,,3657,2559.9,,149.44,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,1828.5,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,318.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,318.54,2486.9,
ASPIR HYDROCELE TUNICA VAGIS W,893523,CDM,360,RC,55000,HCPCS,Outpatient,,,1271,889.7,,83.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,635.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,159.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,889.7,70,,711.76,Percent of Total Billed Charges,70% of Total Billed Charges,953.25,75,,762.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.48,1444.4,
COLONOSCOPY DIAGNOSTIC,893525,CDM,360,RC,45378,HCPCS,Outpatient,,,1621,1134.7,,83.69,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,810.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,345.48,1444.4,
EXC B9 NK HND FT GN 0.6 1.0 CM,893527,CDM,360,RC,11421,HCPCS,Outpatient,,,1271,889.7,,93.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,98.5,Percent of Total Billed Charges,76% of Total Billed Charges,635.5,50,,59.6,Percent of Total Billed Charges,50% of Total Billed Charges,203.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,889.7,70,,711.76,Percent of Total Billed Charges,70% of Total Billed Charges,953.25,75,,762.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,203.24,1444.4,
REVISION OF SCROTUM,893528,CDM,360,RC,55175,HCPCS,Outpatient,,,6280,4396,,360.38,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,3140,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,689.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,689.82,4256.51,
SCROTOPLASTY SIMPLE,893530,CDM,360,RC,55175,HCPCS,Outpatient,,,6280,4396,,360.38,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,190.91,Percent of Total Billed Charges,76% of Total Billed Charges,3140,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,689.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,689.82,4256.51,
EXC FOOT/TOE SC <1.5 CM,893531,CDM,360,RC,28043,HCPCS,Outpatient,,,2874,2011.8,,236.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,1437,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,492.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1979.55,
PARTIAL REMOVAL FOOT FASCIA,893534,CDM,360,RC,28060,HCPCS,Outpatient,,,5785,4049.5,,328.48,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,57.15,Percent of Total Billed Charges,76% of Total Billed Charges,2892.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,679.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
REPAIR ING HERNIA SLIDING,893536,CDM,360,RC,49525,HCPCS,Outpatient,,,6499,4549.3,,527.52,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,116.74,Percent of Total Billed Charges,76% of Total Billed Charges,3249.5,50,,142.8,Percent of Total Billed Charges,50% of Total Billed Charges,1092.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4224.16,
INCISION THROMBOSED HEMORRHOID,893538,CDM,360,RC,46083,HCPCS,Outpatient,,,676,473.2,,100.46,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,338,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,206.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,473.2,70,,378.56,Percent of Total Billed Charges,70% of Total Billed Charges,507,75,,405.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
HEMORRHOIDECTOMY NTRNL XTRNL 1,893540,CDM,360,RC,46255,HCPCS,Outpatient,,,4990,3493,,327.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2495,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,666.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3428.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3428.24,
TRACHEOSTOMY EMERGENCY PROC TR,893543,CDM,360,RC,31603,HCPCS,Outpatient,,,2763,1934.1,,333.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1381.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1862.03,
UNLISTD LAPAROSCOPIC PROC LIVE,893545,CDM,360,RC,47379,HCPCS,Outpatient,,,10335,7234.5,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,972,7045.01,
SIGMOIDOSCOPY FLX W RMVL FOREI,893551,CDM,360,RC,45332,HCPCS,Outpatient,,,2118,1482.6,,95.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1059,50,,1951.2,Percent of Total Billed Charges,50% of Total Billed Charges,197.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,197.34,1444.4,
IRRIGATION CORPORA CAVERNOSA P,893554,CDM,360,RC,54220,HCPCS,Outpatient,,,713,499.1,,131.25,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,356.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,255.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.1,70,,399.28,Percent of Total Billed Charges,70% of Total Billed Charges,534.75,75,,427.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
ENDOSCOPIC INJECTION/IMPLANT,893559,CDM,360,RC,51715,HCPCS,Outpatient,,,4082,2857.4,,176.61,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,162.94,Percent of Total Billed Charges,76% of Total Billed Charges,2041,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,377.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,377.46,4256.51,
INJECTION PETRONIE DISEASE,893563,CDM,360,RC,54200,HCPCS,Outpatient,,,375,262.5,,84.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,187.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,162.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.5,70,,210,Percent of Total Billed Charges,70% of Total Billed Charges,281.25,75,,225,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DIAG LAPARO SEPARATE PROC,893565,CDM,360,RC,49320,HCPCS,Outpatient,,,10335,7234.5,,300.91,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,626.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,626.02,7045.01,
CIRCUMCISION W/CLAMP/OTH DEV/W,893572,CDM,360,RC,54150,HCPCS,Outpatient,,,3710,2597,,95.87,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1855,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,182.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,182.64,2486.9,
EXC B9 LESN MRGN XCP SKNTG S/N,893579,CDM,360,RC,11426,HCPCS,Outpatient,,,5167,3616.9,,233.25,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,2583.5,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,504.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,504.14,3469.39,
EGD DIAGNOSTIC BRUSH WASH,893581,CDM,360,RC,43235,HCPCS,Outpatient,,,1651,1155.7,,111.21,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,292.45,Percent of Total Billed Charges,76% of Total Billed Charges,825.5,50,,90,Percent of Total Billed Charges,50% of Total Billed Charges,229.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,229.2,1444.4,
AMPUTATION TOE & METATARSAL,893583,CDM,360,RC,28810,HCPCS,Outpatient,,,1363,954.1,,386.9,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,116.74,Percent of Total Billed Charges,76% of Total Billed Charges,681.5,50,,987.6,Percent of Total Billed Charges,50% of Total Billed Charges,798.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,954.1,70,,763.28,Percent of Total Billed Charges,70% of Total Billed Charges,1022.25,75,,817.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3952.1,
EXCISION B9 TUMOR/CYST MANIBLE,893586,CDM,360,RC,21040,HCPCS,Outpatient,,,5690,3983,,331.83,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,2845,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,671.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3931.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3931.06,
INCISION AND DRAINAGE PILONIDA,893589,CDM,360,RC,10080,HCPCS,Outpatient,,,1298,908.6,,89.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,649,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,194.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,908.6,70,,726.88,Percent of Total Billed Charges,70% of Total Billed Charges,973.5,75,,778.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,194.84,1444.4,
EXC MAL LESION TRUNK/ARM/LEG 0,893592,CDM,360,RC,11601,HCPCS,Outpatient,,,1298,908.6,,126.61,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,649,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,275.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,908.6,70,,726.88,Percent of Total Billed Charges,70% of Total Billed Charges,973.5,75,,778.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,275.82,1444.4,
EXC HAND LES SC 1.5 CM/>,893595,CDM,360,RC,26111,HCPCS,Outpatient,,,3000,2100,,379.33,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1500,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,785.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
REMOVAL RECTAL OBSTRUCTION,893597,CDM,360,RC,45915,HCPCS,Outpatient,,,2166,1516.2,,210.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1083,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,428.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,428.56,1444.4,
EXCIS SFT TUM BACK FLANK SUBFA,893599,CDM,360,RC,21932,HCPCS,Outpatient,,,5167,3616.9,,607.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,2583.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,1255.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,492,3469.39,
EXC MAL LES FACE/EAR/EYE/NS/LP,893606,CDM,360,RC,11646,HCPCS,Outpatient,,,5167,3616.9,,334.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2583.5,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,730.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3469.39,
FULL THCK HEAD HND 20 SQ CM,893608,CDM,360,RC,15240,HCPCS,Outpatient,,,3452,2416.4,,676.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1726,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,1476.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,2226.59,
REMOVE FECAL MATTER FB ANES,893617,CDM,360,RC,45915,HCPCS,Outpatient,,,2166,1516.2,,210.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,1083,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,428.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,428.56,1444.4,
RPR AA HRN 1ST < 3 NCR/STRN,893618,CDM,360,RC,49592,HCPCS,Outpatient,,,10424,7296.8,,428.78,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,910.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,910.06,7045.01,
RESIN-FOUR OR MORE SURF INVOL,893619,CDM,360,RC,D2335,HCPCS,Outpatient,,,685,479.5,,80.66,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,342.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,479.5,70,,383.6,Percent of Total Billed Charges,70% of Total Billed Charges,513.75,75,,411,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1075.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,796.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,796.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,796.31,100,,,Fee Schedule,100% of CMS OPPS Rate,342.5,1444.4,
CYSTO W FULG AND OR RESECT BLA,893625,CDM,360,RC,52235,HCPCS,Outpatient,,,6410,4487,,253.72,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,196.99,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,542.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,542.86,4256.51,
CYSTO W TRT URETEROPELVIC JU,893626,CDM,360,RC,52342,HCPCS,Outpatient,,,6410,4487,,271.97,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,82.69,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,581.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
PAPILLECTOMY SGL TAG ANUS,893639,CDM,360,RC,46220,HCPCS,Outpatient,,,2166,1516.2,,110.34,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,1083,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,227.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,227.86,1444.4,
DRAINAGE OF EYELID ABSCESS,893646,CDM,360,RC,67700,HCPCS,Outpatient,,,919,643.3,,118.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,315.55,Percent of Total Billed Charges,76% of Total Billed Charges,459.5,50,,11.6,Percent of Total Billed Charges,50% of Total Billed Charges,212.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,643.3,70,,514.64,Percent of Total Billed Charges,70% of Total Billed Charges,689.25,75,,551.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,355.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,263.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.47,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,263.47,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
I & D BART GL&ABSCESS,893647,CDM,360,RC,56420,HCPCS,Outpatient,,,608,425.6,,94.54,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,304,50,,32.4,Percent of Total Billed Charges,50% of Total Billed Charges,206.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.6,70,,340.48,Percent of Total Billed Charges,70% of Total Billed Charges,456,75,,364.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
RPR ENTEROCELE VAG APPRCH,893648,CDM,360,RC,57268,HCPCS,Outpatient,,,9270,6489,,430.89,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4635,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,957,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,6073.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4498.54,100,,,Fee Schedule,100% of CMS OPPS Rate,563,6073.02,
NJX PX NFROSGRM &/URTRGRM,893649,CDM,360,RC,50431,HCPCS,Outpatient,,,1251,875.7,,57.37,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,95.46,Percent of Total Billed Charges,76% of Total Billed Charges,625.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,122.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.7,70,,700.56,Percent of Total Billed Charges,70% of Total Billed Charges,938.25,75,,750.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,122.76,1444.4,
EXC LES SPERMATIC CORD SEP PRO,893656,CDM,360,RC,55520,HCPCS,Outpatient,,,6410,4487,,456.93,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,868.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
INSJ MESH PROSTH PLVC FLR DFCT,893657,CDM,360,RC,57267,HCPCS,Outpatient,,,1364,954.8,,211.74,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,682,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,478.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,954.8,70,,763.84,Percent of Total Billed Charges,70% of Total Billed Charges,1023,75,,818.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
EPIDIDYMECTOMY BILATERAL,893665,CDM,360,RC,54861,HCPCS,Outpatient,,,6410,4487,,561.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,1076.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
CLSD TX CLAVICULAR FX W/O MANI,893668,CDM,360,RC,23500,HCPCS,Outpatient,,,763,534.1,,204.75,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,90.59,Percent of Total Billed Charges,76% of Total Billed Charges,381.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,434.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.1,70,,427.28,Percent of Total Billed Charges,70% of Total Billed Charges,572.25,75,,457.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
EPIDIDYMECTOMY BILATERAL,893671,CDM,360,RC,54861,HCPCS,Outpatient,,,6410,4487,,561.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,71.2,Percent of Total Billed Charges,50% of Total Billed Charges,1076.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
REVISION OF PENIS,893672,CDM,360,RC,54435,HCPCS,Outpatient,,,6410,4487,,408.18,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,783.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,695,4256.51,
EXC TUM FACE SCLP SFT TISS <=2,893676,CDM,360,RC,21014,HCPCS,Outpatient,,,5167,3616.9,,475.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,2583.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,979.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,366,3469.39,
EXC FACE LES SBQ 2 CM/>,893680,CDM,360,RC,21012,HCPCS,Outpatient,,,1108,775.6,,309.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,554,50,,157.6,Percent of Total Billed Charges,50% of Total Billed Charges,637.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,775.6,70,,620.48,Percent of Total Billed Charges,70% of Total Billed Charges,831,75,,664.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,1979.55,
EXC THIGH/KNEE LES SC 3CM/>,893682,CDM,360,RC,27337,HCPCS,Outpatient,,,1370,959,,384.2,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,685,50,,204,Percent of Total Billed Charges,50% of Total Billed Charges,794.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,959,70,,767.2,Percent of Total Billed Charges,70% of Total Billed Charges,1027.5,75,,822,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,3469.39,
EXC SHOULDER LES SC 3CM/>,893684,CDM,360,RC,23071,HCPCS,Outpatient,,,1373,961.1,,384.83,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,686.5,50,,130.4,Percent of Total Billed Charges,50% of Total Billed Charges,795.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.1,70,,768.88,Percent of Total Billed Charges,70% of Total Billed Charges,1029.75,75,,823.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
LAP ING HERNIA REPAIR INIT,893686,CDM,360,RC,49650,HCPCS,Outpatient,,,1413,989.1,,397.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,706.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,822.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,989.1,70,,791.28,Percent of Total Billed Charges,70% of Total Billed Charges,1059.75,75,,847.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7045.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,5218.53,100,,,Fee Schedule,100% of CMS OPPS Rate,706.5,7045.01,
APPLY LOWER LEG SPLINT,5111,CDM,360,RC,29515,HCPCS,Outpatient,,,233,163.1,,44.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,116.5,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,93.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.1,70,,130.48,Percent of Total Billed Charges,70% of Total Billed Charges,174.75,75,,139.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,93.46,1444.4,
APPLY LONG ARM SPLINT,5112,CDM,360,RC,29105,HCPCS,Outpatient,,,270,189,,37.77,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,135,50,,229.2,Percent of Total Billed Charges,50% of Total Billed Charges,80.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189,70,,151.2,Percent of Total Billed Charges,70% of Total Billed Charges,202.5,75,,162,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,80.2,1444.4,
INJ THER CARPAL TUNNEL,6035,CDM,360,RC,20526,HCPCS,Outpatient,,,816,571.2,,52.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,214.02,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,571.2,70,,456.96,Percent of Total Billed Charges,70% of Total Billed Charges,612,75,,489.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
ANAL URINARY MUSCLE STUDY,8100,CDM,360,RC,51784,HCPCS,Outpatient,,,154,107.8,TC,23.96,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,48.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.8,70,,86.24,Percent of Total Billed Charges,70% of Total Billed Charges,115.5,75,,92.4,Percent of Total Billed Charges,75% of Total Billed Charges,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.1,1444.4,
CYSTEOMETROGRAM W/VP & UP,8110,CDM,360,RC,51729,HCPCS,Outpatient,,,275,192.5,TC,111.51,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,137.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,446.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.5,70,,154,Percent of Total Billed Charges,70% of Total Billed Charges,206.25,75,,165,Percent of Total Billed Charges,75% of Total Billed Charges,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,567.15,102,,,Fee Schedule,102% MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,567.15,102,,,Fee Schedule,102% of MO Medicaid rate,556.03,100,,,Fee Schedule,100% of MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,137.5,1444.4,
ELECTRO-UROFLOWMETRY FIRST,8120,CDM,360,RC,51741,HCPCS,Outpatient,,,17,11.9,TC,4.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.9,70,,9.52,Percent of Total Billed Charges,70% of Total Billed Charges,12.75,75,,10.2,Percent of Total Billed Charges,75% of Total Billed Charges,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,1444.4,
INTRAABDOMINAL PRESSURE TEST,8130,CDM,360,RC,51797,HCPCS,Outpatient,,,105,73.5,TC,35.35,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,52.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,210,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,70,,58.8,Percent of Total Billed Charges,70% of Total Billed Charges,78.75,75,,63,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,1444.4,
DEBRID SKIN SBQ TISSUE <= 20 S,9000,CDM,360,RC,11042,HCPCS,Outpatient,,,639,447.3,,51.54,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,319.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,447.3,70,,357.84,Percent of Total Billed Charges,70% of Total Billed Charges,479.25,75,,383.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
ILIOINGUINAL ILIOHYPOGASTRIC N,550247,CDM,360,RC,64425,HCPCS,Outpatient,,,1269,888.3,,47.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,634.5,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,102.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,888.3,70,,710.64,Percent of Total Billed Charges,70% of Total Billed Charges,951.75,75,,761.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,102.78,1444.4,
INJ ANSTH CELIAC PLEXUS,560000,CDM,360,RC,64530,HCPCS,Outpatient,,,2557,1789.9,,80.96,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,177.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.24,1444.4,
INJ ANSTH OTH PERIPHERAL NERVE,560001,CDM,360,RC,64450,HCPCS,Outpatient,,,1933,1353.1,,36.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,103.36,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,1444.4,
ANL SP INF PMP W/MDREPRG&FIL,560002,CDM,360,RC,62370,HCPCS,Outpatient,,,830,581,,39.7,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5832.54,Percent of Total Billed Charges,76% of Total Billed Charges,415,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,86.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581,70,,464.8,Percent of Total Billed Charges,70% of Total Billed Charges,622.5,75,,498,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,364.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,270.13,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.13,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,270.13,100,,,Fee Schedule,100% of CMS OPPS Rate,86.98,1444.4,
NJX AA&/STRD INTERCOSTAL NRV S,560003,CDM,360,RC,64420,HCPCS,Outpatient,,,1933,1353.1,,50.82,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,274.21,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,109.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,109.82,1444.4,
NJX AA&/STRD INTERCOSTAL NRV E,560005,CDM,360,RC,64421,HCPCS,Outpatient,,,2557,1789.9,,21.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,47.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.38,1444.4,
NJX AA&/STRD INTERCOSTAL NRV E,893421,CDM,360,RC,64421,HCPCS,Outpatient,,,2557,1789.9,,21.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,47.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.38,1444.4,
INJ ANSTH ILIOINGUINAL NERVES,893612,CDM,360,RC,64425,HCPCS,Outpatient,,,1933,1353.1,,47.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,102.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,102.78,1444.4,
INTUBATION ENDOTRACHEAL EMERGE,893570,CDM,360,RC,31500,HCPCS,Outpatient,,,10389,7272.3,,147.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,4000,Percent of Total Billed Charges,50% of Total Billed Charges,269.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,100,5000,
UNNA BOOT APPLICATION,723909,CDM,360,RC,29581,HCPCS,Outpatient,,,181,126.7,GP,25.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,72.4,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.7,70,,101.36,Percent of Total Billed Charges,70% of Total Billed Charges,135.75,75,,108.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,1444.4,
I & D HEMA SEROMA FLUID,1014100,CDM,360,RC,10140,HCPCS,Outpatient,,,198,138.6,,101.09,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,99,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,220.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.6,70,,110.88,Percent of Total Billed Charges,70% of Total Billed Charges,148.5,75,,118.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,99,1979.55,
DEBRIDEMENT SUBC TISSUE 20 SQ,1104200,CDM,360,RC,11042,HCPCS,Outpatient,,,342,239.4,,51.54,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,171,50,,136.8,Percent of Total Billed Charges,50% of Total Billed Charges,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.4,70,,191.52,Percent of Total Billed Charges,70% of Total Billed Charges,256.5,75,,205.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/PARING CUTTING BENIGN 2 T,1105600,CDM,360,RC,11056,HCPCS,Outpatient,,,92,64.4,,19.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.4,70,,51.52,Percent of Total Billed Charges,70% of Total Billed Charges,69,75,,55.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,42.16,1444.4,
PROC/PARING 4 OR MORE LESIONS,1105700,CDM,360,RC,11057,HCPCS,Outpatient,,,399,279.3,,24.87,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,199.5,50,,159.6,Percent of Total Billed Charges,50% of Total Billed Charges,55.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.3,70,,223.44,Percent of Total Billed Charges,70% of Total Billed Charges,299.25,75,,239.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55.08,1444.4,
PROC/REMOVAL OF SKIN TAG,1120000,CDM,360,RC,11200,HCPCS,Outpatient,,,107,74.9,,64.52,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.9,70,,59.92,Percent of Total Billed Charges,70% of Total Billed Charges,80.25,75,,64.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,53.5,1444.4,
TRIM NONDYSTROPHIC NAILS,1171900,CDM,360,RC,11719,HCPCS,Outpatient,,,172,120.4,,6.07,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,68.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.4,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,129,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,1444.4,
DEBRID NAILS UP TO 5,1172000,CDM,360,RC,11720,HCPCS,Outpatient,,,148,103.6,,11.8,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,74,50,,59.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.6,70,,82.88,Percent of Total Billed Charges,70% of Total Billed Charges,111,75,,88.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,27.24,1444.4,
DEBRID NAILS 6 PLUS,1172100,CDM,360,RC,11721,HCPCS,Outpatient,,,201,140.7,,19.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,45.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.7,70,,112.56,Percent of Total Billed Charges,70% of Total Billed Charges,150.75,75,,120.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,45.4,1444.4,
AVULSION NAIL PLATE SGL SIMP,1173000,CDM,360,RC,11730,HCPCS,Outpatient,,,308,215.6,,43.06,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,154,50,,123.2,Percent of Total Billed Charges,50% of Total Billed Charges,102.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.6,70,,172.48,Percent of Total Billed Charges,70% of Total Billed Charges,231,75,,184.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/RPR S/N/AX/GEN/TRNK 2.6-7,1200200,CDM,360,RC,12002,HCPCS,Outpatient,,,130,91,,50.88,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,113.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,70,,72.8,Percent of Total Billed Charges,70% of Total Billed Charges,97.5,75,,78,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,65,1444.4,
PROC/DEST MALIGNANT LESION SCA,1727000,CDM,360,RC,17270,HCPCS,Outpatient,,,163,114.1,,80.13,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,81.5,50,,65.2,Percent of Total Billed Charges,50% of Total Billed Charges,178.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.1,70,,91.28,Percent of Total Billed Charges,70% of Total Billed Charges,122.25,75,,97.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,81.5,1444.4,
PROC/BREAST PUNCTURE ASPIRATIO,1900000,CDM,360,RC,19000,HCPCS,Outpatient,,,138,96.6,,36.75,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,69,50,,55.2,Percent of Total Billed Charges,50% of Total Billed Charges,80.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.6,70,,77.28,Percent of Total Billed Charges,70% of Total Billed Charges,103.5,75,,82.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,69,1444.4,
PROC/BREAST BIOPSY PERC. NEEDL,1910000,CDM,360,RC,19100,HCPCS,Outpatient,,,224,156.8,,59.98,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,112,50,,89.6,Percent of Total Billed Charges,50% of Total Billed Charges,132.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.8,70,,125.44,Percent of Total Billed Charges,70% of Total Billed Charges,168,75,,134.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,112,1979.55,
PROC/INJ CARPAL TUNNEL,2052600,CDM,360,RC,20526,HCPCS,Outpatient,,,72,50.4,,52.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,107.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.4,70,,40.32,Percent of Total Billed Charges,70% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,36,1444.4,
PROC/TRIGGER POINT INJ,2055000,CDM,360,RC,20550,HCPCS,Outpatient,,,216,151.2,,35.69,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,108,50,,86.4,Percent of Total Billed Charges,50% of Total Billed Charges,74.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.2,70,,120.96,Percent of Total Billed Charges,70% of Total Billed Charges,162,75,,129.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,74.14,1444.4,
PROC/TENDON INSERTION,2055100,CDM,360,RC,20551,HCPCS,Outpatient,,,83,58.1,,35.72,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,73.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.1,70,,46.48,Percent of Total Billed Charges,70% of Total Billed Charges,62.25,75,,49.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,1444.4,
PROC/TRIGGER POINT(S) SINGLE O,2055200,CDM,360,RC,20552,HCPCS,Outpatient,,,92,64.4,,34.37,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,69.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.4,70,,51.52,Percent of Total Billed Charges,70% of Total Billed Charges,69,75,,55.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,46,1444.4,
PROC/SMALL JOINT BURSE INJ,2060000,CDM,360,RC,20600,HCPCS,Outpatient,,,162,113.4,,32.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,81,50,,64.8,Percent of Total Billed Charges,50% of Total Billed Charges,68.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,70,,90.72,Percent of Total Billed Charges,70% of Total Billed Charges,121.5,75,,97.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,68.06,1444.4,
ARTHRO ASPIR INTERMED JNTS WO,2060500,CDM,360,RC,20605,HCPCS,Outpatient,,,150,105,,33.79,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,69.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.96,1444.4,
ARTHRO ASPIR MAJOR JOINTS WO G,2061000,CDM,360,RC,20610,HCPCS,Outpatient,,,176,123.2,,41.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,88,50,,70.4,Percent of Total Billed Charges,50% of Total Billed Charges,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.2,70,,98.56,Percent of Total Billed Charges,70% of Total Billed Charges,132,75,,105.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,86.18,1444.4,
TENDON SHEATH INSIC TRIGGER FI,2605500,CDM,360,RC,26055,HCPCS,Outpatient,,,1568,1097.6,,266.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,784,50,,627.2,Percent of Total Billed Charges,50% of Total Billed Charges,547.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1097.6,70,,878.08,Percent of Total Billed Charges,70% of Total Billed Charges,1176,75,,940.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1962.35,
PROC/CAST SHORT ARM,2907500,CDM,360,RC,29075,HCPCS,Outpatient,,,159,111.3,,55.58,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,116.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.3,70,,89.04,Percent of Total Billed Charges,70% of Total Billed Charges,119.25,75,,95.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,79.5,1444.4,
PROC/LONG ARM CAST,2910500,CDM,360,RC,29105,HCPCS,Outpatient,,,180,126,,37.77,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,80.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,70,,100.8,Percent of Total Billed Charges,70% of Total Billed Charges,135,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,80.2,1444.4,
PROC/APP SHORT ARM SPLINT,2912500,CDM,360,RC,29125,HCPCS,Outpatient,,,129,90.3,,35.94,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,64.5,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,75.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.3,70,,72.24,Percent of Total Billed Charges,70% of Total Billed Charges,96.75,75,,77.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,64.5,1444.4,
PROC/APP FINGER SPLINT,2913000,CDM,360,RC,29130,HCPCS,Outpatient,,,103,72.1,,26.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,55.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,70,,57.68,Percent of Total Billed Charges,70% of Total Billed Charges,77.25,75,,61.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,51.5,1444.4,
PROC/LONG LEG CAST,2934500,CDM,360,RC,29345,HCPCS,Outpatient,,,274,191.8,,89.79,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,137,50,,109.6,Percent of Total Billed Charges,50% of Total Billed Charges,185.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.8,70,,153.44,Percent of Total Billed Charges,70% of Total Billed Charges,205.5,75,,164.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/SHORT LEG CAST,2940500,CDM,360,RC,29405,HCPCS,Outpatient,,,183,128.1,,52.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,91.5,50,,73.2,Percent of Total Billed Charges,50% of Total Billed Charges,109.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.1,70,,102.48,Percent of Total Billed Charges,70% of Total Billed Charges,137.25,75,,109.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,91.5,1444.4,
PROC/APP SHORT LEG CAST BELOW,2942500,CDM,360,RC,29425,HCPCS,Outpatient,,,353,247.1,,48.79,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,176.5,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,101.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.1,70,,197.68,Percent of Total Billed Charges,70% of Total Billed Charges,264.75,75,,211.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,327.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,242.89,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/APP OF LONG LEG SPLINT,2950500,CDM,360,RC,29505,HCPCS,Outpatient,,,180,126,,46.16,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,97.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126,70,,100.8,Percent of Total Billed Charges,70% of Total Billed Charges,135,75,,108,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,90,1444.4,
PROC/ SHORT LEG SPLINT,2951500,CDM,360,RC,29515,HCPCS,Outpatient,,,144,100.8,,44.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,72,50,,57.6,Percent of Total Billed Charges,50% of Total Billed Charges,93.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.8,70,,80.64,Percent of Total Billed Charges,70% of Total Billed Charges,108,75,,86.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,72,1444.4,
PROC/FOOT STRAPPING,2954000,CDM,360,RC,29540,HCPCS,Outpatient,,,103,72.1,,16.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.1,70,,57.68,Percent of Total Billed Charges,70% of Total Billed Charges,77.25,75,,61.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,33.04,1444.4,
STRAPPING OF TOES,2955000,CDM,360,RC,29550,HCPCS,Outpatient,,,62,43.4,,10.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.4,70,,34.72,Percent of Total Billed Charges,70% of Total Billed Charges,46.5,75,,37.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.36,1444.4,
PROC/MODIFIED COMPRESSION,2958100,CDM,360,RC,29581,HCPCS,Outpatient,,,80,56,,25.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,70,,44.8,Percent of Total Billed Charges,70% of Total Billed Charges,60,75,,48,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,40,1444.4,
PROC/BIOPSY INTRANASAL,3010000,CDM,360,RC,30100,HCPCS,Outpatient,,,221,154.7,,69.68,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,110.5,50,,88.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.7,70,,123.76,Percent of Total Billed Charges,70% of Total Billed Charges,165.75,75,,132.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,110.5,1862.03,
PROC/NASAL ENDOSCOPY,3123100,CDM,360,RC,31231,HCPCS,Outpatient,,,244,170.8,,66.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,122,50,,97.6,Percent of Total Billed Charges,50% of Total Billed Charges,121.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,170.8,70,,136.64,Percent of Total Billed Charges,70% of Total Billed Charges,183,75,,146.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/LARYNGOSCOPY,3157500,CDM,360,RC,31575,HCPCS,Outpatient,,,366,256.2,,69.34,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,183,50,,146.4,Percent of Total Billed Charges,50% of Total Billed Charges,127.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,256.2,70,,204.96,Percent of Total Billed Charges,70% of Total Billed Charges,274.5,75,,219.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,241.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,179.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/URETHRAL CATH SIMPLE,5170100,CDM,360,RC,51701,HCPCS,Outpatient,,,59,41.3,,23.04,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.3,70,,33.04,Percent of Total Billed Charges,70% of Total Billed Charges,44.25,75,,35.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.5,1444.4,
PROC/INSERTION FOLEY CATH,5170200,CDM,360,RC,51702,HCPCS,Outpatient,,,74,51.8,,22.77,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,48.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.8,70,,41.44,Percent of Total Billed Charges,70% of Total Billed Charges,55.5,75,,44.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,37,1444.4,
PROC/SP TUBE CHANGE,5170500,CDM,360,RC,51705,HCPCS,Outpatient,,,98,68.6,,45.48,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,49,50,,39.2,Percent of Total Billed Charges,50% of Total Billed Charges,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.6,70,,54.88,Percent of Total Billed Charges,70% of Total Billed Charges,73.5,75,,58.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,49,1444.4,
PROC/TMT BLADDER LESION,5172000,CDM,360,RC,51720,HCPCS,Outpatient,,,143,100.1,,38.65,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,71.5,50,,57.2,Percent of Total Billed Charges,50% of Total Billed Charges,82.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.1,70,,80.08,Percent of Total Billed Charges,70% of Total Billed Charges,107.25,75,,85.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,71.5,1444.4,
PROC/CMG WITH UPP,5172700,CDM,360,RC,51727,HCPCS,Outpatient,,,202,141.4,,93.83,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,101,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,404,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.4,70,,113.12,Percent of Total Billed Charges,70% of Total Billed Charges,151.5,75,,121.2,Percent of Total Billed Charges,75% of Total Billed Charges,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,567.15,102,,,Fee Schedule,102% MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,567.15,102,,,Fee Schedule,102% of MO Medicaid rate,556.03,100,,,Fee Schedule,100% of MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,101,1444.4,
PROC/CMG WITH VPP,5172800,CDM,360,RC,51728,HCPCS,Outpatient,,,207,144.9,,92.11,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,414,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.9,70,,115.92,Percent of Total Billed Charges,70% of Total Billed Charges,155.25,75,,124.2,Percent of Total Billed Charges,75% of Total Billed Charges,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,567.15,102,,,Fee Schedule,102% MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,567.15,102,,,Fee Schedule,102% of MO Medicaid rate,556.03,100,,,Fee Schedule,100% of MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,103.5,1444.4,
PROC/CMG WITH UPP AND VPP,5172900,CDM,360,RC,51729,HCPCS,Outpatient,,,210,147,,111.51,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,105,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,420,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147,70,,117.6,Percent of Total Billed Charges,70% of Total Billed Charges,157.5,75,,126,Percent of Total Billed Charges,75% of Total Billed Charges,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,567.15,102,,,Fee Schedule,102% MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,567.15,102,,,Fee Schedule,102% of MO Medicaid rate,556.03,100,,,Fee Schedule,100% of MO Medicaid rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,556.03,100,,,Fee Schedule,100% of MO Medicaid Rate,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,105,1444.4,
PROC/UROFLOW,5174100,CDM,360,RC,51741,HCPCS,Outpatient,,,8,5.6,,4.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,70,,4.48,Percent of Total Billed Charges,70% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4,1444.4,
PROC/EMG,5178400,CDM,360,RC,51784,HCPCS,Outpatient,,,114,79.8,,23.96,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,48.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,48.1,1444.4,
PROC/VOIDING PRESSURE TEST,5179700,CDM,360,RC,51797,HCPCS,Outpatient,,,71,49.7,,35.35,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,142,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.7,70,,39.76,Percent of Total Billed Charges,70% of Total Billed Charges,53.25,75,,42.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.5,1444.4,
PROC/BLADDER SCAN,5179800,CDM,360,RC,51798,HCPCS,Outpatient,,,19,13.3,,9.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,19.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.3,70,,10.64,Percent of Total Billed Charges,70% of Total Billed Charges,14.25,75,,11.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,9.5,1444.4,
PROC/MITOMYCIN SINTILLATION TM,5200500,CDM,360,RC,52005,HCPCS,Outpatient,,,342,239.4,,116.83,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,171,50,,136.8,Percent of Total Billed Charges,50% of Total Billed Charges,250.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.4,70,,191.52,Percent of Total Billed Charges,70% of Total Billed Charges,256.5,75,,205.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,171,2486.9,
PROC/TUMT,5385000,CDM,360,RC,53850,HCPCS,Outpatient,,,2121,1484.7,,313.82,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1060.5,50,,848.4,Percent of Total Billed Charges,50% of Total Billed Charges,668.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1200,75,,960,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,492,4256.51,
PROC/INJ TRIMIX,5423500,CDM,360,RC,54235,HCPCS,Outpatient,,,99,69.3,,71.07,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,39.6,Percent of Total Billed Charges,50% of Total Billed Charges,138.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.3,70,,55.44,Percent of Total Billed Charges,70% of Total Billed Charges,74.25,75,,59.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,1444.4,
PROC/FITTING/INSERT OF PESSARY,5716000,CDM,360,RC,57160,HCPCS,Outpatient,,,85,59.5,,38.44,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,87.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.5,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,63.75,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,243.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,42.5,1444.4,
FETAL NON-STRESS TEST,5902500,CDM,360,RC,59025,HCPCS,Outpatient,,,132,92.4,,14.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,66,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.4,70,,73.92,Percent of Total Billed Charges,70% of Total Billed Charges,99,75,,79.2,Percent of Total Billed Charges,75% of Total Billed Charges,162.2,100,,,Fee Schedule,100% of MO Medicaid Rate,243.3,135,,,Fee Schedule,135% of CMS OPPS Rate,165.44,102,,,Fee Schedule,102% MO Medicaid rate,180.22,100,,,Fee Schedule,100% of CMS OPPS rate,165.44,102,,,Fee Schedule,102% of MO Medicaid rate,162.2,100,,,Fee Schedule,100% of MO Medicaid rate,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,162.2,100,,,Fee Schedule,100% of MO Medicaid Rate,180.22,100,,,Fee Schedule,100% of CMS OPPS Rate,34.96,1444.4,
INJ ANSTH OTH PERIPHERAL NERVE,6445000,CDM,360,RC,64450,HCPCS,Outpatient,,,201,140.7,,36.36,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.7,70,,112.56,Percent of Total Billed Charges,70% of Total Billed Charges,150.75,75,,120.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,1444.4,
PROC/ISTIM-TEMP LT,6456100,CDM,360,RC,64561,HCPCS,Outpatient,,,854,597.8,,261.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,427,50,,341.6,Percent of Total Billed Charges,50% of Total Billed Charges,574.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,597.8,70,,478.24,Percent of Total Billed Charges,70% of Total Billed Charges,640.5,75,,512.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,8350.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,427,8350.43,
RMVL FB XTRNL AUDITORY CANAL;,6920000,CDM,360,RC,69200,HCPCS,Outpatient,,,216,151.2,,42.02,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,108,50,,86.4,Percent of Total Billed Charges,50% of Total Billed Charges,89.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.2,70,,120.96,Percent of Total Billed Charges,70% of Total Billed Charges,162,75,,129.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,89.26,1444.4,
PROC/REM IMPACTED-IRRIG UNILAT,6920900,CDM,360,RC,69209,HCPCS,Outpatient,,,49,34.3,,13.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.3,70,,27.44,Percent of Total Billed Charges,70% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,1444.4,
REMOVE IMPACTED CERUMEN IRRIGA,6920950,CDM,360,RC,69209,HCPCS,Outpatient,,,49,34.3,,13.3,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,27.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.3,70,,27.44,Percent of Total Billed Charges,70% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,1444.4,
REMOVE IMPACTED CERUMEN,6921000,CDM,360,RC,69210,HCPCS,Outpatient,,,130,91,,29.4,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,65,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,61.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,70,,72.8,Percent of Total Billed Charges,70% of Total Billed Charges,97.5,75,,78,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,55.32,1444.4,
PROC/REM IMPACTED BILATERAL,6921050,CDM,360,RC,69210,HCPCS,Outpatient,,,120,84,,29.4,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,61.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,70,,67.2,Percent of Total Billed Charges,70% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,55.32,1444.4,
PROC/DEBRIDEMENT MASTOIDECTOMY,6922000,CDM,360,RC,69220,HCPCS,Outpatient,,,140,98,,45.08,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,70,50,,56,Percent of Total Billed Charges,50% of Total Billed Charges,96.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98,70,,78.4,Percent of Total Billed Charges,70% of Total Billed Charges,105,75,,84,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,70,1444.4,
PROC/TYMPANOSTOMY,6943300,CDM,360,RC,69433,HCPCS,Outpatient,,,408,285.6,,116.97,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,204,50,,163.2,Percent of Total Billed Charges,50% of Total Billed Charges,246.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.6,70,,228.48,Percent of Total Billed Charges,70% of Total Billed Charges,306,75,,244.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,671.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,497.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.62,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,497.62,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PROC/TYPANOMETERY,9256700,CDM,360,RC,92567,HCPCS,Outpatient,,,45,31.5,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,22.5,50,,18,Percent of Total Billed Charges,50% of Total Billed Charges,20.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,70,,25.2,Percent of Total Billed Charges,70% of Total Billed Charges,33.75,75,,27,Percent of Total Billed Charges,75% of Total Billed Charges,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,33.3,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,33.3,102,,,Fee Schedule,102% of MO Medicaid rate,32.65,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,20.24,1444.4,
PROC/ISTIM REPROGRAM,9597200,CDM,360,RC,95972,HCPCS,Outpatient,,,120,84,,37.41,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,76.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,70,,67.2,Percent of Total Billed Charges,70% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,118.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,60,1444.4,
PROC/CANALITH REPOSITION PROC.,9599200,CDM,360,RC,95992,HCPCS,Outpatient,,,53,37.1,,33.81,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.1,70,,29.68,Percent of Total Billed Charges,70% of Total Billed Charges,39.75,75,,31.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,45.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,1444.4,
PROC/DEBRIDEMENT FIRST 20 SQ C,9759700,CDM,360,RC,97597,HCPCS,Outpatient,,,118,82.6,,33.45,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,47.2,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.6,70,,66.08,Percent of Total Billed Charges,70% of Total Billed Charges,88.5,75,,70.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,59,1444.4,
REP COMP TRUNK 2.6 TO 7.5CM,201199,CDM,361,RC,13101,HCPCS,Outpatient,,,1605,1123.5,,211.61,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,802.5,50,,507.6,Percent of Total Billed Charges,50% of Total Billed Charges,456.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,802.5,
SMPL RPR SCP-NK-GN-TRNK-XTRM 7,540102,CDM,361,RC,12004,HCPCS,Outpatient,,,430,301,,62.92,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,215,50,,1022.8,Percent of Total Billed Charges,50% of Total Billed Charges,141.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
REPAIR INTERMEDIATE S/A/T/E 12,540104,CDM,361,RC,12035,HCPCS,Outpatient,,,1266,886.2,,206.35,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,633,50,,2157.2,Percent of Total Billed Charges,50% of Total Billed Charges,451.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
CMPLX RPR SCALP ARM LG 2.6-7.5,540106,CDM,361,RC,13121,HCPCS,Outpatient,,,1383,968.1,,219.45,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,691.5,50,,98.4,Percent of Total Billed Charges,50% of Total Billed Charges,480.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,766.83,
INSERT PERIPHERAL CV ACC DEV,540110,CDM,361,RC,36571,HCPCS,Outpatient,,,5542,3879.4,,316.3,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,2771,50,,326.4,Percent of Total Billed Charges,50% of Total Billed Charges,587.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3891.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,587.16,3891.84,
INSERT NON TUNNELL CV CATH 5+,540910,CDM,361,RC,36556,HCPCS,Outpatient,,,3262,2283.4,,85.21,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1631,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,160.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3891.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,3891.84,
LITHOPLAXY COMP>2.5 CM,540917,CDM,361,RC,52318,HCPCS,Outpatient,,,6036,4225.2,,416.9,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,103.97,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,892.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
AMPUTATION OF TOE; MTATRSL JOI,540924,CDM,361,RC,28820,HCPCS,Outpatient,,,5474,3831.8,,163.18,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,26,Percent of Total Billed Charges,50% of Total Billed Charges,339.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,339.18,3952.1,
CMPLX RPR FACE NCK GEN HND FT,540927,CDM,361,RC,13132,HCPCS,Outpatient,,,1534,1073.8,,258.4,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,767,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,563.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,767,
I&D ABSCESS MULT OR COMP,540966,CDM,361,RC,10061,HCPCS,Outpatient,,,691,483.7,,157.32,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,345.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
DEBRID SKIN SBQ TISS MUSC BO<=,540967,CDM,361,RC,11044,HCPCS,Outpatient,,,2745,1921.5,,193.18,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,427.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,1979.55,
CYSTO W FULG AND RESECT TUMOR,540968,CDM,361,RC,52234,HCPCS,Outpatient,,,6036,4225.2,,216.6,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,87.2,Percent of Total Billed Charges,50% of Total Billed Charges,462.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,462.26,4256.51,
CYSTOCOPY AND TRTMENT,540969,CDM,361,RC,52240,HCPCS,Outpatient,,,8462,5923.4,,345.29,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,535.6,Percent of Total Billed Charges,50% of Total Billed Charges,737.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,6317.76,
CYSTOURETERO W STONE REMOVAL,540970,CDM,361,RC,52352,HCPCS,Outpatient,,,6036,4225.2,,311.59,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,666.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
CYSTO W URET PYELOSC BX FULG O,540971,CDM,361,RC,52354,HCPCS,Outpatient,,,1322,925.4,,367.23,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,661,50,,45.6,Percent of Total Billed Charges,50% of Total Billed Charges,784.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,6317.76,
BIOPSY PROSTATE NEEDLE PUNCH,540975,CDM,361,RC,55700,HCPCS,Outpatient,,,3543,2480.1,,127.7,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,246.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,246.58,2486.9,
EGD FLIXIBLE TRANSORAL W BX SN,540979,CDM,361,RC,43239,HCPCS,Outpatient,,,1572,1100.4,,125.24,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,786,50,,236.8,Percent of Total Billed Charges,50% of Total Billed Charges,259.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,1106.79,
DEBRID SKIN SBQ TISSUE<=20 SQ,540992,CDM,361,RC,11042,HCPCS,Outpatient,,,639,447.3,,51.54,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,85.12,Percent of Total Billed Charges,76% of Total Billed Charges,319.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
DEBRID SKIN SBQ TISSUE EA ADDL,540993,CDM,361,RC,11045,HCPCS,Outpatient,,,152,106.4,,22.53,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,76,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.18,644.72,
CMPLX RPR SCALP ARM LG 2.6-7.5,540994,CDM,361,RC,13121,HCPCS,Outpatient,,,1383,968.1,,219.45,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,691.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,480.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,766.83,
SRG PREP GRFT INI 100CM TRNK A,540995,CDM,361,RC,15002,HCPCS,Outpatient,,,3245,2271.5,,188.22,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,412.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,412.74,2226.59,
SRG PREP GRFT ADL 100CM TRNK A,540996,CDM,361,RC,15003,HCPCS,Outpatient,,,1572,1100.4,,39.04,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,786,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,85.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,786,
INCIS PERIANAL ABSCESS SUPE,541007,CDM,361,RC,46050,HCPCS,Outpatient,,,1528,1069.6,,91.44,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,764,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,189.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,189.04,1115.91,
CYSTOURETHROSCOPY W DIL BLADDE,541024,CDM,361,RC,52260,HCPCS,Outpatient,,,3543,2480.1,,185.77,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,396.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,396.24,2486.9,
CYSTOURETHROSCOPY W FULGURAT,541025,CDM,361,RC,52214,HCPCS,Outpatient,,,3543,2480.1,,155.2,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,330.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.58,4256.51,
I & D HEMA SEROMA FLUID,541026,CDM,361,RC,10140,HCPCS,Outpatient,,,2745,1921.5,,101.09,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,220.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,220.6,1979.55,
DEBIRD SBQ MUSC FASCIA<=20CM,541027,CDM,361,RC,11043,HCPCS,Outpatient,,,994,695.8,,131.95,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,497,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,290.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,766.83,
EGD DILAT STRICTURE,541035,CDM,361,RC,43245,HCPCS,Outpatient,,,4976,3483.2,,159.21,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,2488,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,329.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,329.08,2488,
URETAL TUM RESECTN,541037,CDM,361,RC,52355,HCPCS,Outpatient,,,8462,5923.4,,411.09,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,879.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,563,6317.76,
I&D POST OP WND INFECT COMP,541041,CDM,361,RC,10180,HCPCS,Outpatient,,,4637,3245.9,,152.58,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,55.33,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,333.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,333.72,3469.39,
BIOPSY OF PENIS DEEP STRUCTURE,541045,CDM,361,RC,54105,HCPCS,Outpatient,,,4637,3245.9,,209.04,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,401.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,401.94,3469.39,
DEBRID REMOVE FORN MAT SBQ,541054,CDM,361,RC,11012,HCPCS,Outpatient,,,4637,3245.9,,356.83,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,8328.99,Percent of Total Billed Charges,76% of Total Billed Charges,2318.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,783.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,366,3469.39,
LARYNGOSCOPY DIAGNOSTIC,541058,CDM,361,RC,31525,HCPCS,Outpatient,,,2861,2002.7,,165.42,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1430.5,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,301.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2072.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1535.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1535.05,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1535.05,100,,,Fee Schedule,100% of CMS OPPS Rate,301.6,2072.31,
"IMAG GUID FLUID COLLCTN CATH,P",541070,CDM,361,RC,10030,HCPCS,Outpatient,,,2098,1468.6,,116.16,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,291.84,Percent of Total Billed Charges,76% of Total Billed Charges,1049,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,255.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255.22,1049,
INSERT TUN CENT CATH VEN DEVIC,541074,CDM,361,RC,36561,HCPCS,Outpatient,,,8585,6009.5,,336.17,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,492.48,Percent of Total Billed Charges,76% of Total Billed Charges,4292.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3891.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,601.32,4292.5,
CYSTOSCOPY W/TRT URETERAL ST,541075,CDM,361,RC,52341,HCPCS,Outpatient,,,6036,4225.2,,249.76,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,534.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,534.5,4256.51,
TUBE THORACOSTOMY,541084,CDM,361,RC,32551,HCPCS,Outpatient,,,4308,3015.6,,162.84,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,2154,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,295.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1955.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,295.08,2154,
INCIS OF BREAST LESION,541761,CDM,361,RC,19020,HCPCS,Outpatient,,,2745,1921.5,,269.7,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,587.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563,1979.55,
EXC DENTOALVEOLAR LES W/O RPR,541762,CDM,361,RC,41825,HCPCS,Outpatient,,,8382,5867.4,,108.36,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4191,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,224.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,224.34,4191,
ORCHIOPEXY INGUN/SCROT APPR,546400,CDM,361,RC,54640,HCPCS,Outpatient,,,1400,980,,427.16,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,635.36,Percent of Total Billed Charges,76% of Total Billed Charges,700,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,819.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4224.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,601.32,4224.16,
BIOPSY PENIS,550059,CDM,361,RC,54100,HCPCS,Outpatient,,,2745,1921.5,,118.09,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,85.2,Percent of Total Billed Charges,50% of Total Billed Charges,227.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,227.02,1979.55,
CYSTO W/URETERAL CATH,550131,CDM,361,RC,52005,HCPCS,Outpatient,,,3543,2480.1,,116.83,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,250.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,250.34,2486.9,
CYSTOURETHROSCOPY (SEPERATE PR,550141,CDM,361,RC,52000,HCPCS,Outpatient,,,1113,779.1,,71.38,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,556.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,151.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,151.92,834.05,
CYSTOURETHRSCPY W/INSERT INDW,550151,CDM,361,RC,52332,HCPCS,Outpatient,,,6036,4225.2,,136.89,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,292.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,292.2,4256.51,
CYSTOURETHROSCOPY RFB SIMPLE,550164,CDM,361,RC,52310,HCPCS,Outpatient,,,5486,3840.2,,133.32,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2743,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,285.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,285.24,2743,
LITHOPLAXY CRUSH FRAG CALCULUS,550168,CDM,361,RC,52317,HCPCS,Outpatient,,,2784,1948.8,,305.6,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,1392,50,,58.4,Percent of Total Billed Charges,50% of Total Billed Charges,652.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
CHANGE CYSTOSTOMY TUBE COMPLIC,550176,CDM,361,RC,51710,HCPCS,Outpatient,,,1763,1234.1,,70.28,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,881.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,150.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.64,881.5,
CYSTOURETHROSCOPY W BIOPSY(S),550189,CDM,361,RC,52204,HCPCS,Outpatient,,,3543,2480.1,,124.48,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,266.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,266.36,2486.9,
INCIS IMPLANT NEUROSTIM SAC NR,550224,CDM,361,RC,64581,HCPCS,Outpatient,,,2110,1477,,566.56,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,1055,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,1249.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8350.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1098,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,601.32,8350.43,
INSERT REPL PERIPH GI NEUROSTI,550251,CDM,361,RC,64590,HCPCS,Outpatient,,,1408,985.6,,138.08,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,704,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,558.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26709.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19784.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19784.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1481,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,19784.84,100,,,Fee Schedule,100% of CMS OPPS Rate,558.42,26709.55,
COLON CA SCRN NOT HI RISK INDI,550362,CDM,361,RC,45378,HCPCS,Outpatient,,,2431,1701.7,,83.69,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,1215.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,345.48,1215.5,
COLNSCPY FLEX SPLEN BX,550363,CDM,361,RC,45380,HCPCS,Outpatient,,,2008,1405.6,,181.75,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,1004,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,375.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,375.32,1440.83,
COLNSCPY FLEX SPLEN TUM BX,550364,CDM,361,RC,45384,HCPCS,Outpatient,,,2008,1405.6,,207.41,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,1004,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,428.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,428.38,1440.83,
EXC MAL LES TRNK XTRM GRT 4.0,550368,CDM,361,RC,11606,HCPCS,Outpatient,,,2745,1921.5,,271.88,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,424,Percent of Total Billed Charges,50% of Total Billed Charges,594.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,1979.55,
EGD INJ SCLEROSIS,550372,CDM,361,RC,43243,HCPCS,Outpatient,,,3114,2179.8,,214.99,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,1557,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,445.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,445.32,2323.29,
COLORECTAL SCRN; NOT HI RSK IN,550379,CDM,361,RC,45378,HCPCS,Outpatient,,,2431,1701.7,,83.69,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,1215.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,345.48,1215.5,
CYSTOURETHROSCPY W CALIB DILAT,550403,CDM,361,RC,52281,HCPCS,Outpatient,,,3543,2480.1,,133.85,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,285.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,285.76,2486.9,
DESTR LES PENIS EXT,550404,CDM,361,RC,54065,HCPCS,Outpatient,,,3245,2271.5,,167.6,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1622.5,50,,83.6,Percent of Total Billed Charges,50% of Total Billed Charges,320.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,320.82,2226.59,
REPLAC GTUBE REVJ GSTRST TRC,550422,CDM,361,RC,43763,HCPCS,Outpatient,,,1030,721,,77.15,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,570.91,Percent of Total Billed Charges,76% of Total Billed Charges,515,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,164.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
CYSTO W/DIRECT VISION INTERP,550424,CDM,361,RC,52276,HCPCS,Outpatient,,,3543,2480.1,,232.74,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,496.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,496.92,2486.9,
EGD PLACE PERC TUBE,550427,CDM,361,RC,43246,HCPCS,Outpatient,,,3114,2179.8,,181.73,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1557,50,,29.2,Percent of Total Billed Charges,50% of Total Billed Charges,376.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,376.18,2323.29,
REPLAC GASTRO TUBE PERQ WO GUI,550428,CDM,361,RC,43762,HCPCS,Outpatient,,,736,515.2,,33.81,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,368,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,71.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,71.58,644.72,
ESOPHAGOSC DILATE BALLOON 30,550444,CDM,361,RC,43214,HCPCS,Outpatient,,,610,427,,175.06,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,305,50,,82,Percent of Total Billed Charges,50% of Total Billed Charges,364.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,305,2323.29,
CMPLX RPR LID NS EAR LIP 1.1 2,550493,CDM,361,RC,13151,HCPCS,Outpatient,,,1379,965.3,,237.71,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,689.5,50,,1.6,Percent of Total Billed Charges,50% of Total Billed Charges,518.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,766.83,
EXCIS BEN LES FACE 3.1 4.0CM,550571,CDM,361,RC,11444,HCPCS,Outpatient,,,2745,1921.5,,193.32,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,2.8,Percent of Total Billed Charges,50% of Total Billed Charges,421.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,1979.55,
SIGMOID FLEX DIAGNOSTIC,550573,CDM,361,RC,45330,HCPCS,Outpatient,,,1528,1069.6,,50.64,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,764,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,105.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,105.44,1115.91,
EGD REMOVE FOREIGN BODY,550576,CDM,361,RC,43247,HCPCS,Outpatient,,,1572,1100.4,,160.52,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,786,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,330.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,330.76,1106.79,
EXC B9 LESN MRGN XCP SK TK T/A,550580,CDM,361,RC,11406,HCPCS,Outpatient,,,2745,1921.5,,212.65,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,466.42,1979.55,
EXCIS BEN LES FACE 2.1 3.0 CM,550581,CDM,361,RC,11443,HCPCS,Outpatient,,,2745,1921.5,,152.58,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,146.53,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,333.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,333.22,1979.55,
CMPLX RPR FACE NCK GEN HND FT,550583,CDM,361,RC,13131,HCPCS,Outpatient,,,1263,884.1,,206.46,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,631.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,450.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
EXC B9 LESN MRGN XCP SK TG T/A,550585,CDM,361,RC,11403,HCPCS,Outpatient,,,1907,1334.9,,126.56,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,953.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,277.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,277.82,953.5,
EXC B9 LESN MRGN XCP SK TG T/A,550587,CDM,361,RC,11404,HCPCS,Outpatient,,,4311,3017.7,,140.16,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,2155.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,306.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,306.7,2155.5,
ASPIR BLAD WINSERT SUPRAP CATH,550601,CDM,361,RC,51102,HCPCS,Outpatient,,,3543,2480.1,,127.97,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,112.4,Percent of Total Billed Charges,50% of Total Billed Charges,269.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,269.04,2486.9,
CYSTO W FULG WO W BX,550602,CDM,361,RC,52224,HCPCS,Outpatient,,,2444,1710.8,,179.77,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1222,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,382.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,382.6,4256.51,
CYSTOURETHROS W URETERSCOP DIA,550603,CDM,361,RC,52351,HCPCS,Outpatient,,,6036,4225.2,,266.25,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,570.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
CIRCUMCISION/28 DAYS OR OLDER,550606,CDM,361,RC,54161,HCPCS,Outpatient,,,3543,2480.1,,194.55,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1771.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,372.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,372.78,2486.9,
PERC IMPLNT NEUROSTIM SAC NRV,550610,CDM,361,RC,64561,HCPCS,Outpatient,,,12373,8661.1,,261.1,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,5000,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,574.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8350.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,6185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,574.84,8350.43,
REVERSE REMOVE NEUROELECTRODES,550611,CDM,361,RC,64585,HCPCS,Outpatient,,,6296,4407.2,,123.15,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3148,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,269.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4154.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS Rate,269.72,4154.39,
REVIS RMV PERIF GASTR NEUROSTI,550612,CDM,361,RC,64595,HCPCS,Outpatient,,,6296,4407.2,,108.72,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3148,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,433.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4154.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3077.34,100,,,Fee Schedule,100% of CMS OPPS Rate,433.88,4154.39,
INCIS REMOV FB SUBQ COMP,550613,CDM,361,RC,10121,HCPCS,Outpatient,,,2745,1921.5,,157.84,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,344.46,1979.55,
EGD REMOVE FOREIGN BODY,550617,CDM,361,RC,43247,HCPCS,Outpatient,,,1572,1100.4,,160.52,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,170.24,Percent of Total Billed Charges,76% of Total Billed Charges,786,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,330.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,330.76,1106.79,
I & D PILON CYST COMP,550618,CDM,361,RC,10081,HCPCS,Outpatient,,,1220,854,,147.12,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,153.22,Percent of Total Billed Charges,76% of Total Billed Charges,610,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,321.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,321.58,859.04,
DEBRID SBQ MUSC FASCIA<= 20CM,550620,CDM,361,RC,11043,HCPCS,Outpatient,,,994,695.8,,131.95,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,99.71,Percent of Total Billed Charges,76% of Total Billed Charges,497,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,290.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,766.83,
ABDMNL PARCENTESIS W IMAG GUID,550623,CDM,361,RC,49083,HCPCS,Outpatient,,,1572,1100.4,,96.41,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,786,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,198.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,198.72,1106.79,
EXC B9 LESN MRGN XCP SK TG T/A,550625,CDM,361,RC,11406,HCPCS,Outpatient,,,2745,1921.5,,212.65,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,466.42,1979.55,
DRAIN FINGER ABSCESS COMP,550626,CDM,361,RC,26011,HCPCS,Outpatient,,,2745,1921.5,,169.13,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,346.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,346.12,1979.55,
CYSTO WCATH W BRSH BX URETR&OR,550637,CDM,361,RC,52007,HCPCS,Outpatient,,,6036,4225.2,,145.7,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,312.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,312.68,4256.51,
REMOVAL OF SKIN TAGS UP TO 15,550640,CDM,361,RC,11200,HCPCS,Outpatient,,,349,244.3,,64.52,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,174.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
EXC FACE-MM B9+MARG 0.5 CM/<,550658,CDM,361,RC,11440,HCPCS,Outpatient,,,448,313.6,,89.71,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,78.43,Percent of Total Billed Charges,76% of Total Billed Charges,224,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,195.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.98,859.04,
DESTRUCT B9 LESION 1-14,550660,CDM,361,RC,17110,HCPCS,Outpatient,,,354,247.8,,56.64,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,177,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
DRAINAGE OF SCROTUM,550662,CDM,361,RC,54700,HCPCS,Outpatient,,,675,472.5,,210.11,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,184.22,Percent of Total Billed Charges,76% of Total Billed Charges,337.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,402.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2486.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1842.15,100,,,Fee Schedule,100% of CMS OPPS Rate,337.5,2486.9,
EXC FACE-MM B9+MARG 1.1-2 CM,550667,CDM,361,RC,11442,HCPCS,Outpatient,,,617,431.9,,124.76,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,308.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,272.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,272.36,859.04,
REVISE SPERMATIC CORD VEINS,550888,CDM,361,RC,55530,HCPCS,Outpatient,,,1675,1172.5,,348.99,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,837.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,666.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
ADHESIOLYSIS TUBE OVARY,550893,CDM,361,RC,58740,HCPCS,Outpatient,,,2916,2041.2,,764.89,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,236.51,Percent of Total Billed Charges,76% of Total Billed Charges,1458,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,1716.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2916,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,2916,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2916,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2916,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,563,2916,
I&D OF VULVA/PERINEUM,550901,CDM,361,RC,56405,HCPCS,Outpatient,,,470,329,,107.76,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,235,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
EXC TR-EXT B9 MARG 0.6-1CM,551507,CDM,361,RC,11401,HCPCS,Outpatient,,,497,347.9,,90.17,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,248.5,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,195.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
AMPUTAT TOE MTATRSL PHLNGL,893391,CDM,361,RC,28820,HCPCS,Outpatient,,,5474,3831.8,,163.18,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,2737,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,339.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,339.18,3952.1,
EXC TAGS MULTI PAPILLAE,893392,CDM,361,RC,46230,HCPCS,Outpatient,,,4688,3281.6,,157.55,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,2344,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,327.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3428.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,327.84,3428.24,
EXC HYPRPLSTC ALVELR MUCSA EA,893404,CDM,361,RC,41828,HCPCS,Outpatient,,,4145,2901.5,,201.81,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,2072.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,415.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.84,2072.5,
SIGMOIDOSCPY FLX W/BIOPSY SING,893406,CDM,361,RC,45331,HCPCS,Outpatient,,,2431,1701.7,,64.7,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1794.21,Percent of Total Billed Charges,76% of Total Billed Charges,1215.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,134.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,134.8,1215.5,
EXCISN OF VAGINAL CYST OR TUMO,893408,CDM,361,RC,57135,HCPCS,Outpatient,,,8039,5627.3,,159.1,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,4019.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,354.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3817.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,354.1,4019.5,
ENUCLEATN EXT THROMB HEMORR,893413,CDM,361,RC,46320,HCPCS,Outpatient,,,3177,2223.9,,103.45,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,1588.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,213.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,213.76,1588.5,
AMPUTATION TOE INTERPHALANGEAL,893547,CDM,361,RC,28825,HCPCS,Outpatient,,,5785,4049.5,,158.54,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2892.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,330.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3952.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2927.48,100,,,Fee Schedule,100% of CMS OPPS Rate,330.72,3952.1,
CYSTO URETERO PELVIC STRICTURE,893637,CDM,361,RC,52345,HCPCS,Outpatient,,,6410,4487,,347.14,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3205,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,742.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,563,4256.51,
COLL OF BLOOD VENOUS ACCESS DE,5528,CDM,361,RC,36591,HCPCS,Outpatient,,,86,60.2,,26.49,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,418.91,Percent of Total Billed Charges,76% of Total Billed Charges,43,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,47.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,43,644.72,
REMOVAL SUTR/STAPL XREQ ANES,158530,CDM,361,RC,15853,HCPCS,Outpatient,,,36,25.2,,9.62,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.08,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,644.72,
NJX INTERLAMINAR LMBR/SAC W GU,550232,CDM,361,RC,62323,HCPCS,Outpatient,,,1933,1353.1,,85.44,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,187.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,187.54,966.5,
NJX INTERLAMINAR CRV/THRC W GU,550233,CDM,361,RC,62321,HCPCS,Outpatient,,,1933,1353.1,,92.22,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,202.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,202.76,966.5,
RF ABLTJ NRV NRVTG SI JT,550234,CDM,361,RC,64625,HCPCS,Outpatient,,,5393,3775.1,,167.84,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2696.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,368.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2357.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,368.24,2696.5,
ARTHRO ASPIR MAJOR JOINTS WO G,550235,CDM,361,RC,20610,HCPCS,Outpatient,,,816,571.2,,41.14,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,86.18,644.72,
INJ SACROILIAC JOINT ARTHOGRAP,550236,CDM,361,RC,27096,HCPCS,Outpatient,,,1933,1353.1,,74.92,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,966.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,156.2,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,966.5,
INJ DX THX AGNT VRTBRFCT LC JN,550237,CDM,361,RC,64493,HCPCS,Outpatient,,,2557,1789.9,,77.15,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,169.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,169.82,1278.5,
INJ DX THX AGNT VRTBRFCT LS JN,550238,CDM,361,RC,64494,HCPCS,Outpatient,,,600,420,,44.14,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,300,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,96.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.5,644.72,
INJ DX THX AGNT VRTBRFCT LS JN,550239,CDM,361,RC,64495,HCPCS,Outpatient,,,607,424.9,,44.71,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,303.5,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,98.22,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.22,644.72,
INJ ANSTH TRANS EPI LUM SGL LV,550241,CDM,361,RC,64483,HCPCS,Outpatient,,,2557,1789.9,,95.61,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,209.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,209.06,1278.5,
ARTHRO ASPIR INTERMED JNTS WO,550242,CDM,361,RC,20605,HCPCS,Outpatient,,,816,571.2,,33.79,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,41.95,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,69.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.96,644.72,
INJ DX THX AGNT VRTBRFCT CT JN,550243,CDM,361,RC,64490,HCPCS,Outpatient,,,2557,1789.9,,90.88,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,198.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,198.02,1278.5,
INJ DX THX AGNT VRTBRFCT CT JN,550244,CDM,361,RC,64491,HCPCS,Outpatient,,,661,462.7,,51.22,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,330.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,112.44,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,644.72,
INJ DX THX AGNT VRTBRFCT CT JN,550245,CDM,361,RC,64492,HCPCS,Outpatient,,,669,468.3,,51.79,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,334.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,114.16,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,644.72,
INJ TRIGGER POINT 1-2 MUSCL,550246,CDM,361,RC,20552,HCPCS,Outpatient,,,816,571.2,,34.37,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,112.8,Percent of Total Billed Charges,50% of Total Billed Charges,69.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.7,644.72,
INJ TRIGGER POINT 3+ MUSCL,550248,CDM,361,RC,20553,HCPCS,Outpatient,,,816,571.2,,39.02,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,644.72,
NJX INTERLAMINAR LMBR/SAC WO G,550249,CDM,361,RC,62322,HCPCS,Outpatient,,,2557,1789.9,,69.89,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1278.5,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,150.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1112.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,824.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.8,1278.5,
DSTR NROLYTC AGNT PVB FCT SNGL,550253,CDM,361,RC,64633,HCPCS,Outpatient,,,5393,3775.1,,164.88,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2696.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,361.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2357.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,361.86,2696.5,
DSTR NROLYTC AGNT PVB FCT SNGL,550254,CDM,361,RC,64635,HCPCS,Outpatient,,,5393,3775.1,,164.9,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2696.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,362.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2357.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1746.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.44,2696.5,
INJ TENDON SHEATH LIGAMENT,550262,CDM,361,RC,20550,HCPCS,Outpatient,,,816,571.2,,35.69,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,74.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,74.14,644.72,
INJ ANSTH GRTER OCCIPITAL NERV,550263,CDM,361,RC,64405,HCPCS,Outpatient,,,816,571.2,,45.46,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,213.41,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,100.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
INSERT TEMP BLADDER CATH,550264,CDM,361,RC,51702,HCPCS,Outpatient,,,199,139.3,,22.77,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,76.61,Percent of Total Billed Charges,76% of Total Billed Charges,99.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,48.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,48.04,644.72,
INJ ANSTH TRANS EPI LUM EA ADD,550301,CDM,361,RC,64484,HCPCS,Outpatient,,,2365,1655.5,,44.43,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,71.74,Percent of Total Billed Charges,76% of Total Billed Charges,1182.5,50,,124,Percent of Total Billed Charges,50% of Total Billed Charges,97.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.64,1182.5,
ARTRO ASPIR SMALL JOINT WO GUI,893512,CDM,361,RC,20600,HCPCS,Outpatient,,,816,571.2,,32.55,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,68.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,68.06,644.72,
CHOLANGIOGRAPHY;POSTOP; S&I; X,813420,CDM,361,RC,47531,HCPCS,Outpatient,,,1382,967.4,,63.16,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,691,50,,552.8,Percent of Total Billed Charges,50% of Total Billed Charges,131,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4224.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,695,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3129.01,100,,,Fee Schedule,100% of CMS OPPS Rate,131,4224.17,
PROC/INC & RMVL FB SUBQ TISS S,1012000,CDM,361,RC,10120,HCPCS,Outpatient,,,484,338.8,,88.5,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,242,50,,193.6,Percent of Total Billed Charges,50% of Total Billed Charges,195.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,644.72,
ENDOTRACH INTUBATION,6900,CDM,370,RC,31500,HCPCS,Outpatient,,,431,301.7,,147.31,100,,,fee schedule,100% Aetna Market fee schedule,293.08,68,,234.46,Percent of Total Billed Charges,68% of Total Billed Charges,327.56,76,,262.05,Percent of Total Billed Charges,76% of Total Billed Charges,215.5,50,,172.4,Percent of Total Billed Charges,50% of Total Billed Charges,269.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,215.5,327.56,
MOD SED SAME PHYS/QHP 5/>YRS,540919,CDM,371,RC,99152,HCPCS,Outpatient,,,88,61.6,,11.6,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,66.88,76,,237.12,Percent of Total Billed Charges,76% of Total Billed Charges,44,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,23.16,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.16,66.88,
MOD SED SAME PHYS/QHP EA,540920,CDM,371,RC,99153,HCPCS,Outpatient,,,19,13.3,,9.73,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.16,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,20.16,
ESOPHAGOSC DILATE BALLOON 30,550445,CDM,375,RC,43214,HCPCS,Outpatient,,,200,140,,175.06,100,,,fee schedule,100% Aetna Market fee schedule,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,152,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,100,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,364.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,100,2323.29,
PACKED CELLS TRANSFUSION,307125,CDM,380,RC,Y7507,HCPCS,Outpatient,,,697,487.9,,,,,,Other,Not Seperately Reimbusable,473.96,68,,379.17,Percent of Total Billed Charges,68% of Total Billed Charges,529.72,76,,34.82,Percent of Total Billed Charges,76% of Total Billed Charges,348.5,50,,61.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.5,529.72,
BLOOD PROCESSING & STORAGE-EA,307100,CDM,390,RC,P9016,HCPCS,Outpatient,,,101,70.7,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,5.44,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,244.1,
RBC LEUKOCYTE REDUCED EA UNIT,307148,CDM,390,RC,P9016,HCPCS,Outpatient,,,577,403.9,,9.6,100,,,fee schedule,100% Aetna Market fee schedule,392.36,68,,313.89,Percent of Total Billed Charges,68% of Total Billed Charges,438.52,76,,83.78,Percent of Total Billed Charges,76% of Total Billed Charges,288.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.82,100,,,Fee Schedule,100% of CMS OPPS Rate,180.82,438.52,
RED BLOOD CELLS WASHED EA UNIT,307150,CDM,390,RC,P9022,HCPCS,Outpatient,,,388,271.6,,41.43,100,,,fee schedule,100% Aetna Market fee schedule,263.84,68,,211.07,Percent of Total Billed Charges,68% of Total Billed Charges,294.88,76,,23.39,Percent of Total Billed Charges,76% of Total Billed Charges,194,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,397.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.12,100,,,Fee Schedule,100% of CMS OPPS Rate,194,536.11,
PLATELETS EA UNIT,307200,CDM,390,RC,P9019,HCPCS,Outpatient,,,218,152.6,,39.49,100,,,fee schedule,100% Aetna Market fee schedule,148.24,68,,118.59,Percent of Total Billed Charges,68% of Total Billed Charges,165.68,76,,31.55,Percent of Total Billed Charges,76% of Total Billed Charges,109,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate,65.04,165.68,
PLATELETS PHERESIS LEUKOCYTE R,307210,CDM,390,RC,P9035,HCPCS,Outpatient,,,1491,1043.7,,40,100,,,fee schedule,100% Aetna Market fee schedule,1013.88,68,,811.1,Percent of Total Billed Charges,68% of Total Billed Charges,1133.16,76,,64.19,Percent of Total Billed Charges,76% of Total Billed Charges,745.5,50,,65.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,637.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.33,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,1133.16,
LEUKO REDUCED PLATELLETS EA UN,307215,CDM,390,RC,P9031,HCPCS,Outpatient,,,459,321.3,,35.06,100,,,fee schedule,100% Aetna Market fee schedule,312.12,68,,249.7,Percent of Total Billed Charges,68% of Total Billed Charges,348.84,76,,11.42,Percent of Total Billed Charges,76% of Total Billed Charges,229.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.88,100,,,Fee Schedule,100% of CMS OPPS Rate,130.88,348.84,
LEUKOCYTES RDCD BLD CMV - EACH,307220,CDM,390,RC,P9051,HCPCS,Outpatient,,,651,455.7,,50.64,100,,,fee schedule,100% Aetna Market fee schedule,442.68,68,,354.14,Percent of Total Billed Charges,68% of Total Billed Charges,494.76,76,,11.42,Percent of Total Billed Charges,76% of Total Billed Charges,325.5,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,167.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.25,100,,,Fee Schedule,100% of CMS OPPS Rate,167.25,494.76,
AUTOLOGOUS WHOLE BLOOD,307250,CDM,390,RC,Y9010,HCPCS,Outpatient,,,460,322,,,,,,Other,Not Seperately Reimbusable,312.8,68,,250.24,Percent of Total Billed Charges,68% of Total Billed Charges,349.6,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,230,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,230,349.6,
PLATELETS PHERESIS EA UNIT,307300,CDM,390,RC,P9034,HCPCS,Outpatient,,,992,694.4,,113.85,100,,,fee schedule,100% Aetna Market fee schedule,674.56,68,,539.65,Percent of Total Billed Charges,68% of Total Billed Charges,753.92,76,,70.72,Percent of Total Billed Charges,76% of Total Billed Charges,496,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,321.86,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,321.86,100,,,Fee Schedule,100% of CMS OPPS Rate,321.86,753.92,
FRESH FROZEN PLASMA PER UNIT,308800,CDM,390,RC,P9017,HCPCS,Outpatient,,,253,177.1,,33.52,100,,,fee schedule,100% Aetna Market fee schedule,172.04,68,,137.63,Percent of Total Billed Charges,68% of Total Billed Charges,192.28,76,,32.1,Percent of Total Billed Charges,76% of Total Billed Charges,126.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.95,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,192.28,
TRANSFUSION-BLOOD /DAY,307217,CDM,391,RC,36430,HCPCS,Outpatient,,,292,204.4,,37.87,100,,,fee schedule,100% Aetna Market fee schedule,198.56,68,,158.85,Percent of Total Billed Charges,68% of Total Billed Charges,221.92,76,,583.71,Percent of Total Billed Charges,76% of Total Billed Charges,146,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,72.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,72.84,530.02,
BLOOD COMP DERIV ADMIN PER DAY,550261,CDM,391,RC,36430,HCPCS,Outpatient,,,1164,814.8,,37.87,100,,,fee schedule,100% Aetna Market fee schedule,791.52,68,,633.22,Percent of Total Billed Charges,68% of Total Billed Charges,884.64,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,582,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,72.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,72.84,884.64,
US GUIDE NEEDLE PLACEMENT,541013,CDM,402,RC,76942,HCPCS,Outpatient,,,116,81.2,,27.76,100,,,fee schedule,100% Aetna Market fee schedule,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,78.88,68,,1155.52,Percent of Total Billed Charges,68% of Total Billed Charges,58,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.68,105,
US BREAST,890177,CDM,402,RC,76641,HCPCS,Outpatient,,,336,235.2,,36.06,100,,,fee schedule,100% Aetna Market fee schedule,228.48,68,,182.78,Percent of Total Billed Charges,68% of Total Billed Charges,228.48,68,,182.78,Percent of Total Billed Charges,68% of Total Billed Charges,168,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,117.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,228.48,
US CHEST B SCAN,890190,CDM,402,RC,76604,HCPCS,Outpatient,,,275,192.5,,28.69,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,137.5,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,52.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,52.1,187,
US OB 1ST TRIMESTER <14 WKS,890200,CDM,402,RC,76801,HCPCS,Outpatient,,,440,308,,48.71,100,,,fee schedule,100% Aetna Market fee schedule,299.2,68,,239.36,Percent of Total Billed Charges,68% of Total Billed Charges,299.2,68,,239.36,Percent of Total Billed Charges,68% of Total Billed Charges,220,50,,176,Percent of Total Billed Charges,50% of Total Billed Charges,121.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,299.2,
US OB LIMITED,890210,CDM,402,RC,76815,HCPCS,Outpatient,,,413,289.1,,32.19,100,,,fee schedule,100% Aetna Market fee schedule,280.84,68,,224.67,Percent of Total Billed Charges,68% of Total Billed Charges,280.84,68,,224.67,Percent of Total Billed Charges,68% of Total Billed Charges,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,87,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,87,280.84,
US ABDOMEN TECH,890225,CDM,402,RC,76700,HCPCS,Outpatient,,,104,72.8,TC,39.92,100,,,fee schedule,100% Aetna Market fee schedule,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,52,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,135.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,52,135.1,
US ABDOMINAL LIMITED,890227,CDM,402,RC,76705,HCPCS,Outpatient,,,428,299.6,,29.37,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,102.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US ABDOMEN PROF,890230,CDM,402,RC,76700,HCPCS,Outpatient,,,58,40.6,26,39.92,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,29,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,116,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,29,134.22,
US ABDOMINAL AORTA,890232,CDM,402,RC,76706,HCPCS,Outpatient,,,120,84,,27.27,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,139.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,60,139.04,
US ARTERIAL UPPER EXTR UNILATE,890237,CDM,402,RC,93931,HCPCS,Outpatient,,,398,278.6,,22.06,100,,,fee schedule,100% Aetna Market fee schedule,270.64,68,,216.51,Percent of Total Billed Charges,68% of Total Billed Charges,270.64,68,,216.51,Percent of Total Billed Charges,68% of Total Billed Charges,199,50,,159.2,Percent of Total Billed Charges,50% of Total Billed Charges,172.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,270.64,
US OB 2ND TRIMESTER W/ ANATOMY,890240,CDM,402,RC,76811,HCPCS,Outpatient,,,572,400.4,,84.61,100,,,fee schedule,100% Aetna Market fee schedule,388.96,68,,311.17,Percent of Total Billed Charges,68% of Total Billed Charges,388.96,68,,311.17,Percent of Total Billed Charges,68% of Total Billed Charges,286,50,,228.8,Percent of Total Billed Charges,50% of Total Billed Charges,151.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,105,388.96,
US OB ADD'L 2ND TRIMESTER W/ A,890241,CDM,402,RC,76812,HCPCS,Outpatient,,,623,436.1,,88.64,100,,,fee schedule,100% Aetna Market fee schedule,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,249.2,Percent of Total Billed Charges,50% of Total Billed Charges,185.44,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,423.64,
US OB 2ND TRIMESTER >14 WEEKS,890245,CDM,402,RC,76805,HCPCS,Outpatient,,,482,337.4,,49.05,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,327.76,
US OB 3RD TRIMESTER; COMPLETE,890250,CDM,402,RC,76805,HCPCS,Outpatient,,,441,308.7,,49.05,100,,,fee schedule,100% Aetna Market fee schedule,299.88,68,,239.9,Percent of Total Billed Charges,68% of Total Billed Charges,299.88,68,,239.9,Percent of Total Billed Charges,68% of Total Billed Charges,220.5,50,,176.4,Percent of Total Billed Charges,50% of Total Billed Charges,152.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,299.88,
US RETROPERITONEAL;COMPLETE,890251,CDM,402,RC,76770,HCPCS,Outpatient,,,428,299.6,,36.41,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,126.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US ABDOMEN COMPLETE,890252,CDM,402,RC,76700,HCPCS,Outpatient,,,428,299.6,,39.92,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,135.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US RUQ ABDOMEN LIMITED,890253,CDM,402,RC,76705,HCPCS,Outpatient,,,428,299.6,,29.37,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,102.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US PELVIC-NON OB,890254,CDM,402,RC,76856,HCPCS,Outpatient,,,428,299.6,,34.29,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US ECHO SCROTUM AND CONTENTS,890256,CDM,402,RC,76870,HCPCS,Outpatient,,,428,299.6,,31.83,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,120.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US SOFT TISSUE OF HEAD & NECK,890257,CDM,402,RC,76536,HCPCS,Outpatient,,,428,299.6,,28.3,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,144.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US TRANSVAGINAL,890258,CDM,402,RC,76830,HCPCS,Outpatient,,,428,299.6,,34.29,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,149.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US BLADDER,890259,CDM,402,RC,76857,HCPCS,Outpatient,,,275,192.5,,24.2,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,137.5,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,45.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,187,
US W/GUIDANCE - TECH,890260,CDM,402,RC,76942,HCPCS,Outpatient,,,880,616,TC,27.76,100,,,fee schedule,100% Aetna Market fee schedule,598.4,68,,478.72,Percent of Total Billed Charges,68% of Total Billed Charges,598.4,68,,478.72,Percent of Total Billed Charges,68% of Total Billed Charges,440,50,,352,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.68,598.4,
"US ECHO OF EXTREMITY, NON VASC",890261,CDM,402,RC,76881,HCPCS,Outpatient,,,428,299.6,,28.78,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,18.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.94,291.04,
US RENAL,890262,CDM,402,RC,76770,HCPCS,Outpatient,,,275,192.5,,36.41,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,137.5,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,126.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,187,
US GUIDANCE VAS ACCESS,890263,CDM,402,RC,76937,HCPCS,Outpatient,,,482,337.4,,14.02,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,42.38,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.38,327.76,
US TRANSRECTAL TECH,890266,CDM,402,RC,76872,HCPCS,Outpatient,,,428,299.6,TC,33.34,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,290.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US OB ADD'L 3RD TRIMESTER; COM,890275,CDM,402,RC,76810,HCPCS,Outpatient,,,428,299.6,,42.34,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.98,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.98,291.04,
US OB ADD'L 1ST TRIMESTER <14,890280,CDM,402,RC,76802,HCPCS,Outpatient,,,200,140,,21.69,100,,,fee schedule,100% Aetna Market fee schedule,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,100,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,36.02,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.02,136,
US ADDITIONAL GESTATION >14 WK,890282,CDM,402,RC,76810,HCPCS,Outpatient,,,125,87.5,,42.34,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,62.5,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,70.98,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,105,
US OB FOLLOW UP,890300,CDM,402,RC,76816,HCPCS,Outpatient,,,372,260.4,,42.37,100,,,fee schedule,100% Aetna Market fee schedule,252.96,68,,202.37,Percent of Total Billed Charges,68% of Total Billed Charges,252.96,68,,202.37,Percent of Total Billed Charges,68% of Total Billed Charges,186,50,,148.8,Percent of Total Billed Charges,50% of Total Billed Charges,120.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,252.96,
US FETAL BIOPHYSICAL PROFILE,890351,CDM,402,RC,76818,HCPCS,Outpatient,,,428,299.6,,52.21,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,119.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,291.04,
US FETAL BIOPHYSICAL W/O NON S,890355,CDM,402,RC,76819,HCPCS,Outpatient,,,358,250.6,,38.5,100,,,fee schedule,100% Aetna Market fee schedule,243.44,68,,194.75,Percent of Total Billed Charges,68% of Total Billed Charges,243.44,68,,194.75,Percent of Total Billed Charges,68% of Total Billed Charges,179,50,,143.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,85.36,243.44,
US KIDNEY,890376,CDM,402,RC,76775,HCPCS,Outpatient,,,428,299.6,,28.68,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.23,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,291.04,
PNEUMATIC COMPRESS.,721575,CDM,410,RC,97016,HCPCS,Outpatient,,,74,51.8,,9.2,100,,,fee schedule,100% Aetna Market fee schedule,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,37,50,,29.6,Percent of Total Billed Charges,50% of Total Billed Charges,21.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.89,60,
POSTURAL DRAINAGE,721600,CDM,410,RC,,,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,31.2,65,,24.96,Percent of Total Billed Charges,65% of Total Billed Charges,36,75,,28.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,28.8,60,,23.04,Percent of Total Billed Charges,60% of Total Billed Charges,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.79,20.4,,7.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,9.6,20,,7.68,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.6,60,
AEROSOL THER. SET-UP,850350,CDM,410,RC,94640,HCPCS,Outpatient,,,49,34.3,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
DRUG NEBULIZER SUBSEQUENT,850400,CDM,410,RC,94640,HCPCS,Outpatient,,,49,34.3,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
AEROSOL MIST/HR,850420,CDM,410,RC,94640,HCPCS,Outpatient,,,49,34.3,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
ALUPENT TO .3CC,850421,CDM,410,RC,Y7506,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,60,
APNEA MONITOR SETUP,850426,CDM,410,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,60,
ALBUTEROL TO OR <.25,850428,CDM,410,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,60,
ALBUTEROL >.25CC,850429,CDM,410,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,60,
ASTHMA NEFRIN TO.5CC,850432,CDM,410,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,60,
ATROVENT  (2.5ML),850433,CDM,410,RC,Y7506,HCPCS,Outpatient,25,ML,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,60,
COMP. AIR PER HOUR,850440,CDM,410,RC,Y7506,HCPCS,Outpatient,,,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.5,60,
DISP HEATER COLUMN,850442,CDM,410,RC,Y7506,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,60,
DISPOSABLE THERMO,850444,CDM,410,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,60,
NEO-SYNEPHRINE 1% UD,850451,CDM,410,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,60,
I.P.P.B. SET-UP,850550,CDM,410,RC,94640,HCPCS,Outpatient,,,61,42.7,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
I.P.P.B. SUBSEQUENT,850600,CDM,410,RC,94640,HCPCS,Outpatient,,,61,42.7,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
METER DOSE INHALER,850680,CDM,410,RC,94640,HCPCS,Outpatient,,,61,42.7,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
METERED DOSE INHALER; SUBSEQUE,850685,CDM,410,RC,94640,HCPCS,Outpatient,,,61,42.7,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
CROUP TENT PER HR,850701,CDM,410,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,60,
CROUP TENT-12 HRS,850705,CDM,410,RC,Y7506,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,63.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,120.84,
DEMONSTRATION\EVALUATION,850710,CDM,410,RC,94664,HCPCS,Outpatient,,,49,34.3,,15.27,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,260.42,
MUCOMYST 20% EA/CC,850725,CDM,410,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,60,
MUCUS SPEC. TRAP,850736,CDM,410,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,60,
ULT.NEBULIZER SETUP,850759,CDM,410,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,60,
NEBULIZER TRMNT-30MN,850760,CDM,410,RC,Y7506,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,60,
STERILE WATER 3CC/<,850868,CDM,410,RC,Y7506,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,60,
STERILE WATER 1000ML,850870,CDM,410,RC,Y7506,HCPCS,Outpatient,1000,ML,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,60,
STERILE WATER-1550ML,850871,CDM,410,RC,Y7506,HCPCS,Outpatient,50,ML,11,7.7,,,,,,Other,Not Seperately Reimbusable,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,60,
VENT FEED SET,850943,CDM,410,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,60,
VENTILATOR PER DAY,850944,CDM,410,RC,94002,HCPCS,Outpatient,,,400,280,,85.26,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,174.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,765.13,
VENTILATOR SET-UP,850950,CDM,410,RC,Y7506,HCPCS,Outpatient,,,400,280,,,,,,Other,Not Seperately Reimbusable,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,160,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,304,
VENTILATOR STANDBY,851000,CDM,410,RC,Y7506,HCPCS,Outpatient,,,234,163.8,,,,,,Other,Not Seperately Reimbusable,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,177.84,
VOLDYNE VOLUM.EXERC,851025,CDM,410,RC,Y7506,HCPCS,Outpatient,,,38,26.6,,,,,,Other,Not Seperately Reimbusable,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,60,
OXYGEN CYLINDER/CART,851202,CDM,410,RC,Y7506,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,60,
OXYHOOD-PER HOUR,851345,CDM,410,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,60,
OXYGEN PRN,851350,CDM,410,RC,Y7506,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,60,
REBREATHER O2 MASK,851550,CDM,410,RC,Y7506,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,60,
REGULATOR/DAY,851554,CDM,410,RC,Y7506,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,60,
STAT. CHARGE,851640,CDM,410,RC,Y7506,HCPCS,Outpatient,,,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,60,
TRACH TUBE STRAP,851699,CDM,410,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,60,
FLOW METER PER DAY,851851,CDM,410,RC,Y7506,HCPCS,Outpatient,,,17,11.9,,,,,,Other,Not Seperately Reimbusable,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,60,
LG.BORE AEROSOL TBG.,851950,CDM,410,RC,Y7506,HCPCS,Outpatient,,,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,60,
SAT. MONITOR/HR.,852035,CDM,410,RC,94762,HCPCS,Outpatient,,,24,16.8,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,43.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12,190.72,
ADULT RESUSCITN.BAG,852100,CDM,410,RC,Y7506,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,60,
SENSOR-INFANT,852301,CDM,410,RC,Y7506,HCPCS,Outpatient,,,88,61.6,,,,,,Other,Not Seperately Reimbusable,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,66.88,76,,53.5,Percent of Total Billed Charges,76% of Total Billed Charges,44,50,,35.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44,66.88,
PULSE OXIMETRY 24HR,852304,CDM,410,RC,94762,HCPCS,Outpatient,,,154,107.8,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,43.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,43.52,190.72,
SPUTUM INDUCTION,852305,CDM,410,RC,94664,HCPCS,Outpatient,,,61,42.7,,15.27,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,31.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,260.42,
SPUTUM COLLECTION,852306,CDM,410,RC,89220,HCPCS,Outpatient,,,58,40.6,,12.26,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,33.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,154.47,100,,,Fee Schedule,100% of CMS OPPS Rate,29,208.54,
TRACHEAL SUCTION,852307,CDM,410,RC,31720,HCPCS,Outpatient,,,234,163.8,,61.67,100,,,fee schedule,100% Aetna Market fee schedule,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,92.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,260.42,
CPAP-SET UP,852311,CDM,410,RC,94660,HCPCS,Outpatient,,,234,163.8,,34.96,100,,,fee schedule,100% Aetna Market fee schedule,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,260.42,
CPAP CONT./HOURS,852313,CDM,410,RC,93041,HCPCS,Outpatient,,,120,84,,5.17,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,91.2,
C PAP/BI PAP INITIATION,852314,CDM,410,RC,93041,HCPCS,Outpatient,,,533,373.1,,5.17,100,,,fee schedule,100% Aetna Market fee schedule,362.44,68,,289.95,Percent of Total Billed Charges,68% of Total Billed Charges,405.08,76,,324.06,Percent of Total Billed Charges,76% of Total Billed Charges,266.5,50,,213.2,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,405.08,
C PAP/ BI PAP PER DAY,852315,CDM,410,RC,94660,HCPCS,Outpatient,,,233,163.1,,34.96,100,,,fee schedule,100% Aetna Market fee schedule,158.44,68,,126.75,Percent of Total Billed Charges,68% of Total Billed Charges,177.08,76,,141.66,Percent of Total Billed Charges,76% of Total Billed Charges,116.5,50,,93.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,260.42,
NON-PRESSURIZED INHALATION TRE,852319,CDM,410,RC,94640,HCPCS,Outpatient,,,68,47.6,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
C D N FIRST HOUR,852321,CDM,410,RC,94644,HCPCS,Outpatient,,,191,133.7,,55.67,100,,,fee schedule,100% Aetna Market fee schedule,129.88,68,,103.9,Percent of Total Billed Charges,68% of Total Billed Charges,145.16,76,,116.13,Percent of Total Billed Charges,76% of Total Billed Charges,95.5,50,,76.4,Percent of Total Billed Charges,50% of Total Billed Charges,102.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,60,155.96,
C D N EACH ADDTL HOUR,852323,CDM,410,RC,94645,HCPCS,Outpatient,,,167,116.9,,14.35,100,,,fee schedule,100% Aetna Market fee schedule,113.56,68,,90.85,Percent of Total Billed Charges,68% of Total Billed Charges,126.92,76,,101.54,Percent of Total Billed Charges,76% of Total Billed Charges,83.5,50,,66.8,Percent of Total Billed Charges,50% of Total Billed Charges,28.08,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.08,126.92,
VENTILATION ASSIST & MANAGEMEN,852325,CDM,410,RC,94002,HCPCS,Outpatient,,,400,280,,85.26,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,174.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,765.13,
VENTILATION ASSIST & MGMT;SUBS,852326,CDM,410,RC,94003,HCPCS,Outpatient,,,400,280,,59.98,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,122.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,566.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60,765.13,
CPAP/BIPAP;INITIATION & MANAGE,852327,CDM,410,RC,94660,HCPCS,Outpatient,,,533,373.1,,34.96,100,,,fee schedule,100% Aetna Market fee schedule,362.44,68,,289.95,Percent of Total Billed Charges,68% of Total Billed Charges,405.08,76,,324.06,Percent of Total Billed Charges,76% of Total Billed Charges,266.5,50,,213.2,Percent of Total Billed Charges,50% of Total Billed Charges,70.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,405.08,
CHEST PHYSIOTHERAPY INITIAL,852329,CDM,410,RC,94667,HCPCS,Outpatient,,,75,52.5,,20.45,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,43.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,37.5,155.96,
MANIPULATION CHESTWALL;SUBSEQU,852330,CDM,410,RC,94668,HCPCS,Outpatient,,,117,81.9,,31.77,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,88.92,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,58.5,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,58.5,155.96,
CONT DRUG NEBULIZER-PER DAY,852364,CDM,410,RC,94640,HCPCS,Outpatient,,,134,93.8,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,81.47,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,53.6,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
NON PRESSURE INHALATN TRT,9464000,CDM,410,RC,94640,HCPCS,Outpatient,,,145,101.5,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,98.6,68,,78.88,Percent of Total Billed Charges,68% of Total Billed Charges,110.2,76,,88.16,Percent of Total Billed Charges,76% of Total Billed Charges,72.5,50,,58,Percent of Total Billed Charges,50% of Total Billed Charges,13.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,260.42,135,,,Fee Schedule,135% of CMS OPPS Rate,177.09,102,,,Fee Schedule,102% MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS rate,177.09,102,,,Fee Schedule,102% of MO Medicaid rate,173.62,100,,,Fee Schedule,100% of MO Medicaid rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Case Rate,Pays based on per visit rate,173.62,100,,,Fee Schedule,100% of MO Medicaid Rate,192.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.8,260.42,
EAR PULSE OX SGL DETER,9476000,CDM,410,RC,94760,HCPCS,Outpatient,,,8,5.6,,2.11,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,60,
THERAPEUTIC EXERCISE (15 MIN),720400,CDM,420,RC,97110,HCPCS,Outpatient,,,110,77,,18.44,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,54.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,150,
CONTRAST BATH,720850,CDM,420,RC,97034,HCPCS,Outpatient,,,85,59.5,,11.29,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,26.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,150,
SELECTIVE DEBRIDEMENT A,721000,CDM,420,RC,97597,HCPCS,Outpatient,,,275,192.5,,33.45,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55,244.43,
SELECTIVE DEBRIDEMENT B,721025,CDM,420,RC,97598,HCPCS,Outpatient,,,351,245.7,,23.23,100,,,fee schedule,100% Aetna Market fee schedule,238.68,68,,190.94,Percent of Total Billed Charges,68% of Total Billed Charges,266.76,76,,213.41,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,46.9,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.9,266.76,
NON-SELECTIVE DEBRIDEMENT,721050,CDM,420,RC,97602,HCPCS,Outpatient,,,367,256.9,,82.4,100,,,fee schedule,100% Aetna Market fee schedule,249.56,68,,199.65,Percent of Total Billed Charges,68% of Total Billed Charges,278.92,76,,223.14,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55,278.92,
ELECTRIC STIMULATION,721100,CDM,420,RC,97032,HCPCS,Outpatient,,,106,74.2,,10.42,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,27,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,150,
E-STIM NON-WOUND UNATTENDED,721145,CDM,420,RC,97014,HCPCS,Outpatient,,,74,51.8,,6.56,100,,,fee schedule,100% Aetna Market fee schedule,50.32,68,,40.26,Percent of Total Billed Charges,68% of Total Billed Charges,56.24,76,,44.99,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,22.92,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.92,150,
GAIT TRAINING,721200,CDM,420,RC,97116,HCPCS,Outpatient,,,96,67.2,,22.88,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,54.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,27.31,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,150,
SELF CARE/ HOME INSTRUCTION,721238,CDM,420,RC,97535,HCPCS,Outpatient,,,119,83.3,,25.44,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
IONTOPHORESIS (15 MIN),721300,CDM,420,RC,97033,HCPCS,Outpatient,,,85,59.5,GP,15.21,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,35.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.84,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,17.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17.84,150,
MASSAGE,721400,CDM,420,RC,97124,HCPCS,Outpatient,,,106,74.2,,13.56,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,55.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.7,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.7,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,27.7,100,,,Fee Schedule,100% of CMS OPPS Rate,27.7,150,
MANUAL THERAPY,721450,CDM,420,RC,97140,HCPCS,Outpatient,,,110,77,,12.95,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,50.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.21,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.21,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,25.21,100,,,Fee Schedule,100% of CMS OPPS Rate,25.21,150,
NEUROMUSCLE EXERCISE (15 MIN),721500,CDM,420,RC,97112,HCPCS,Outpatient,,,110,77,GP,26.54,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,62.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,31.26,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.26,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,31.26,100,,,Fee Schedule,100% of CMS OPPS Rate,31.26,150,
ORTHOTIC FIT/TRAINING,721520,CDM,420,RC,97760,HCPCS,Outpatient,,,85,59.5,GP,37.58,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,86.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.27,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,43.27,100,,,Fee Schedule,100% of CMS OPPS Rate,43.27,150,
PARAFIN BATH,721550,CDM,420,RC,97018,HCPCS,Outpatient,,,106,74.2,,4.42,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,150,
PROSTHETIC TRAINING,721605,CDM,420,RC,97761,HCPCS,Outpatient,,,117,81.9,GP,32.18,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,88.92,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,76.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.12,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.12,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,38.12,100,,,Fee Schedule,100% of CMS OPPS Rate,38.12,150,
STERILE WHIRLPOOL,721750,CDM,420,RC,97022,HCPCS,Outpatient,,,181,126.7,,13.29,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,137.56,76,,110.05,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,15.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.41,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,15.41,100,,,Fee Schedule,100% of CMS OPPS Rate,15.41,150,
ULTRASOUND (15 MIN),721900,CDM,420,RC,97035,HCPCS,Outpatient,,,119,83.3,,7.72,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,26.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,150,
VASOPNEUMATIC TX,721910,CDM,420,RC,97016,HCPCS,Outpatient,,,63,44.1,,9.2,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,21.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.89,150,
SM-HYDROCOLLATOR PKS,722500,CDM,420,RC,97010,HCPCS,Outpatient,,,53,37.1,,3.48,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,11.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,150,
THER/FUNC ACTIVITIES (15 MIN),722870,CDM,420,RC,97530,HCPCS,Outpatient,,,121,84.7,GP,28.77,100,,,fee schedule,100% Aetna Market fee schedule,82.28,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,91.96,76,,73.57,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,67.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.55,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,33.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.55,150,
MECH TRACTION,723750,CDM,420,RC,97012,HCPCS,Outpatient,,,85,59.5,,5.22,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,26.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,150,
OVERHEAD FRAME W/TRA,723900,CDM,420,RC,97012,HCPCS,Outpatient,,,159,111.3,,5.22,100,,,fee schedule,100% Aetna Market fee schedule,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,96.67,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,26.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.22,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,150,
UNLISTED MODALITIES (15 MIN),723905,CDM,420,RC,97039,HCPCS,Outpatient,,,85,59.5,GP,8,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,150,
UNLISTED THER. PROCEDURE (15 M,723908,CDM,420,RC,97139,HCPCS,Outpatient,,,106,74.2,GP,13.51,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,150,
WHEELCHAIR TRAINING (15 MIN),723910,CDM,420,RC,97542,HCPCS,Outpatient,,,106,74.2,GP,24.71,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,58.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.45,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,29.45,100,,,Fee Schedule,100% of CMS OPPS Rate,29.45,150,
WORK HARDENING 1 (INITIAL 2HOU,723915,CDM,420,RC,97545,HCPCS,Outpatient,,,211,147.7,GP,130.16,100,,,fee schedule,100% Aetna Market fee schedule,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,160.36,
WORK HARDENING 2 (EACH ADD'L H,723920,CDM,420,RC,97546,HCPCS,Outpatient,,,106,74.2,GP,51.46,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,150,
PT RE-EVALUATION,720350,CDM,424,RC,97164,HCPCS,Outpatient,,,226,158.2,,53.54,100,,,fee schedule,100% Aetna Market fee schedule,153.68,68,,122.94,Percent of Total Billed Charges,68% of Total Billed Charges,171.76,76,,137.41,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,128.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,64.38,100,,,Fee Schedule,100% of CMS OPPS Rate,55,171.76,
EVALUATION TECH,721150,CDM,424,RC,97001,HCPCS,Outpatient,,,211,147.7,,,,,,Other,Not Seperately Reimbusable,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,160.36,
PT EVALUATION-LOW,721160,CDM,424,RC,97161,HCPCS,Outpatient,,,330,231,,77.84,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,186.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
PT EVALUATION-MOD,721170,CDM,424,RC,97162,HCPCS,Outpatient,,,330,231,,77.84,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,186.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
PT EVALUATION-HIGH,721180,CDM,424,RC,97163,HCPCS,Outpatient,,,330,231,,77.84,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,200.64,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,186.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,93.44,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
COGNITIVE TRAINING/15 MIN,530017,CDM,430,RC,97532,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,2965.82,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.8,150,
COMMUNITY/WORK RE-INTEGRATION,530019,CDM,430,RC,97535,HCPCS,Outpatient,,,106,74.2,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,13.98,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,5.6,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
CONTRAST BATH,530021,CDM,430,RC,97535,HCPCS,Outpatient,,,85,59.5,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,3.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
DEVELOPMENTAL TESTING,530025,CDM,430,RC,97703,HCPCS,Outpatient,,,275,192.5,EP,,,,,Other,Not Seperately Reimbusable,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,209,
E-STIMULATION,530029,CDM,430,RC,97032,HCPCS,Outpatient,,,106,74.2,EP,10.42,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,3.2,Case Rate,Pays based on per visit rate,27,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,150,
HOT/COLD PACKS,530050,CDM,430,RC,97535,HCPCS,Outpatient,,,57,39.9,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,17.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
IONTOPHORESIS,530055,CDM,430,RC,97535,HCPCS,Outpatient,,,85,59.5,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,43.17,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,35.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
MANUAL THERAPY,530065,CDM,430,RC,97535,HCPCS,Outpatient,,,110,77,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,7.6,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
MASSAGE,530069,CDM,430,RC,97535,HCPCS,Outpatient,,,106,74.2,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,61.6,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
MUSCLE TESTING/TOTAL,530075,CDM,430,RC,97535,HCPCS,Outpatient,,,322,225.4,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,218.96,68,,175.17,Percent of Total Billed Charges,68% of Total Billed Charges,244.72,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,244.72,
NEUROMUSCULAR RE-EDUCATION,530080,CDM,430,RC,97535,HCPCS,Outpatient,,,110,77,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,44.8,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
ORTHOTICS TRNG/FITTING,530085,CDM,430,RC,97535,HCPCS,Outpatient,,,154,107.8,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,8,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
PARAFFIN BATH,530090,CDM,430,RC,97535,HCPCS,Outpatient,,,106,74.2,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,1.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
PHYSICAL PERFORMANCE TEST,530093,CDM,430,RC,97750,HCPCS,Outpatient,,,275,192.5,GO,25.96,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,4.8,Case Rate,Pays based on per visit rate,62.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,31.31,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.31,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,31.31,100,,,Fee Schedule,100% of CMS OPPS Rate,31.31,209,
PROSTHETIC/ORTHOTIC CHECKOUT,530095,CDM,430,RC,97535,HCPCS,Outpatient,,,106,74.2,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,2494,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
PROSTHETIC TRAINING,530097,CDM,430,RC,97535,HCPCS,Outpatient,,,154,107.8,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,976.45,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,5.6,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
ROM MEASUREMENTS/HAND,530100,CDM,430,RC,97535,HCPCS,Outpatient,,,275,192.5,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,14.8,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,209,
ROM MEASUREMENTS/LIMB,530103,CDM,430,RC,97535,HCPCS,Outpatient,,,275,192.5,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,14,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,209,
SELF CARE/HOME MNGT TRNG,530122,CDM,430,RC,97535,HCPCS,Outpatient,,,119,83.3,GO,25.44,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,1501.15,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,7.6,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
SENSORY INTEGRATION,530125,CDM,430,RC,97535,HCPCS,Outpatient,,,119,83.3,GO,25.44,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,750.88,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,95.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
STERILE WHIRLPOOL,530140,CDM,430,RC,97535,HCPCS,Outpatient,,,112,78.4,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,20.4,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
THERAPEUTIC ACTIVITIES,530150,CDM,430,RC,97535,HCPCS,Outpatient,,,110,77,GO,25.44,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,18.4,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
THERAPEUTIC EXERCISE,530152,CDM,430,RC,97535,HCPCS,Outpatient,,,110,77,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,18.8,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
THERAPEUTIC GROUP,530154,CDM,430,RC,97535,HCPCS,Outpatient,,,65,45.5,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,1098.05,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,18.8,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
ULTRASOUND,530160,CDM,430,RC,97535,HCPCS,Outpatient,,,119,83.3,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,47.2,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
VASOPNEUMATIC DEVICE,530163,CDM,430,RC,97016,HCPCS,Outpatient,,,65,45.5,GO,9.2,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,30,Case Rate,Pays based on per visit rate,21.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,10.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.89,150,
WHEELCHAIR MNGT,530165,CDM,430,RC,97535,HCPCS,Outpatient,,,106,74.2,EP,25.44,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,24.4,Case Rate,Pays based on per visit rate,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,150,
WORK HARDENING,530170,CDM,430,RC,97545,HCPCS,Outpatient,,,211,147.7,GO,130.16,100,,,fee schedule,100% Aetna Market fee schedule,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,0.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,160.36,
OT EVALUATION-LOW COMPLEXITY,530005,CDM,434,RC,97165,HCPCS,Outpatient,,,330,231,EP,78.36,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,206.72,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,143.2,Case Rate,Pays based on per visit rate,188.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
OT EVALUATION-MODERATE COMPLEX,530006,CDM,434,RC,97166,HCPCS,Outpatient,,,330,231,EP,78.36,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,1.6,Case Rate,Pays based on per visit rate,188.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
OT EVALUATION-HIGH COMPLEXITY,530007,CDM,434,RC,97167,HCPCS,Outpatient,,,330,231,EP,78.36,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,3.2,Case Rate,Pays based on per visit rate,188.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,94.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,250.8,
OT RE-EVALUATION,530009,CDM,434,RC,97168,HCPCS,Outpatient,,,137,95.9,EP,53.79,100,,,fee schedule,100% Aetna Market fee schedule,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,82.08,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,122,Case Rate,Pays based on per visit rate,129.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.66,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,64.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55,150,
COGNITIVE FUNCTION INTERVENTIO,530020,CDM,440,RC,97129,HCPCS,Outpatient,,,108,75.6,,17.81,100,,,fee schedule,100% Aetna Market fee schedule,73.44,68,,58.75,Percent of Total Billed Charges,68% of Total Billed Charges,82.08,76,,65.66,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,42.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.25,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.25,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,21.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.25,150,
COGNITIVE SKILLS EVAL 15 MIN,720840,CDM,440,RC,96125,HCPCS,Outpatient,,,333,233.1,,96.07,100,,,fee schedule,100% Aetna Market fee schedule,226.44,68,,181.15,Percent of Total Billed Charges,68% of Total Billed Charges,253.08,76,,202.46,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,191.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.99,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.99,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,95.99,100,,,Fee Schedule,100% of CMS OPPS Rate,55,253.08,
ASSESS OF APHASIA,870152,CDM,440,RC,96105,HCPCS,Outpatient,,,75,52.5,,90.91,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,150,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS Rate,51,150,
AURAL REHABILITATION W/ COCHLE,870155,CDM,440,RC,92510,HCPCS,Outpatient,,,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,150,
SPEECH THERAPY- ADULT,870500,CDM,440,RC,92507,HCPCS,Outpatient,,,250,175,GN,63.43,100,,,fee schedule,100% Aetna Market fee schedule,170,68,,136,Percent of Total Billed Charges,68% of Total Billed Charges,190,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,143.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,190,
SWALLOWING TREAT,870560,CDM,440,RC,92526,HCPCS,Outpatient,,,276,193.2,,78.78,100,,,fee schedule,100% Aetna Market fee schedule,187.68,68,,150.14,Percent of Total Billed Charges,68% of Total Billed Charges,209.76,76,,167.81,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,158.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,209.76,
EVAL USE/FIT VOICE PROSTHETIC,870600,CDM,440,RC,92507,HCPCS,Outpatient,,,257,179.9,,63.43,100,,,fee schedule,100% Aetna Market fee schedule,174.76,68,,139.81,Percent of Total Billed Charges,68% of Total Billed Charges,195.32,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,143.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,195.32,
THER SVC/SPEECH GEN DEV (15 MI,870650,CDM,440,RC,92609,HCPCS,Outpatient,,,53,37.1,,96.12,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,191.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,191.66,
EVAL FOR SPEECH GENERATING DEV,870700,CDM,440,RC,,,Outpatient,,,1238,866.6,,,,,,Other,Not Seperately Reimbusable,841.84,68,,673.47,Percent of Total Billed Charges,68% of Total Billed Charges,940.88,76,,752.7,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,804.7,65,,643.76,Percent of Total Billed Charges,65% of Total Billed Charges,928.5,75,,742.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.6,20,,198.08,Percent of Total Billed Charges,20% of Total Billed Charges,742.8,60,,594.24,Percent of Total Billed Charges,60% of Total Billed Charges,252.55,20.4,,202.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,252.55,20.4,,202.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,247.6,20,,198.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,247.6,20,,198.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,940.88,
ADDTL 30 MIN SPEECH GEN DEVICE,870710,CDM,440,RC,,,Outpatient,,,175,122.5,,,,,,Other,Not Seperately Reimbusable,119,68,,95.2,Percent of Total Billed Charges,68% of Total Billed Charges,133,76,,106.4,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,113.75,65,,91,Percent of Total Billed Charges,65% of Total Billed Charges,131.25,75,,105,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,20,,28,Percent of Total Billed Charges,20% of Total Billed Charges,105,60,,84,Percent of Total Billed Charges,60% of Total Billed Charges,35.7,20.4,,28.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35.7,20.4,,28.56,Percent of Total Billed Charges,20.4% of Total Billed Charges,35,20,,28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,35,20,,28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,35,150,
EVAL FOR SPEECH GEN DEVICE,870800,CDM,440,RC,92597,HCPCS,Outpatient,,,1238,866.6,,66.97,100,,,fee schedule,100% Aetna Market fee schedule,841.84,68,,673.47,Percent of Total Billed Charges,68% of Total Billed Charges,940.88,76,,752.7,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,136.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,68.11,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.11,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,68.11,100,,,Fee Schedule,100% of CMS OPPS Rate,55,940.88,
SPEECH THERAPY- CHILD,871010,CDM,440,RC,92507,HCPCS,Outpatient,,,250,175,EP,63.43,100,,,fee schedule,100% Aetna Market fee schedule,170,68,,136,Percent of Total Billed Charges,68% of Total Billed Charges,190,76,,152,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,143.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,190,
SWALLOWING TREATMENT,871030,CDM,440,RC,92526,HCPCS,Outpatient,,,276,193.2,,78.78,100,,,fee schedule,100% Aetna Market fee schedule,187.68,68,,150.14,Percent of Total Billed Charges,68% of Total Billed Charges,209.76,76,,167.81,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,158.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,79.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55,209.76,
EVAL USE/FITTING VOICE PROSTHE,871060,CDM,440,RC,92507,HCPCS,Outpatient,,,257,179.9,,63.43,100,,,fee schedule,100% Aetna Market fee schedule,174.76,68,,139.81,Percent of Total Billed Charges,68% of Total Billed Charges,195.32,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,143.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,71.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55,195.32,
ASSESSMENT OF APHASIA,871070,CDM,440,RC,96105,HCPCS,Outpatient,,,350,245,,90.91,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,181.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,90.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,90.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,266,
THERAPEUTIC SVC/SPEECH GENERAT,871080,CDM,440,RC,92609,HCPCS,Outpatient,,,257,179.9,,96.12,100,,,fee schedule,100% Aetna Market fee schedule,174.76,68,,139.81,Percent of Total Billed Charges,68% of Total Billed Charges,195.32,76,,156.26,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,191.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,95.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,195.32,
SPEECH THERAPY GROUP 15 MIN,870450,CDM,443,RC,92508,HCPCS,Outpatient,,,77,53.9,YG,19.56,100,,,fee schedule,100% Aetna Market fee schedule,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,58.52,76,,46.82,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,44.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS Rate,22.46,150,
SPEECH THERAPY GROUP,871050,CDM,443,RC,92508,HCPCS,Outpatient,,,137,95.9,YG,19.56,100,,,fee schedule,100% Aetna Market fee schedule,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,44.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,22.46,100,,,Fee Schedule,100% of CMS OPPS Rate,22.46,150,
SPEECH PATH EVAL,870300,CDM,444,RC,92522,HCPCS,Outpatient,,,362,253.4,YG,92.33,100,,,fee schedule,100% Aetna Market fee schedule,246.16,68,,196.93,Percent of Total Billed Charges,68% of Total Billed Charges,275.12,76,,220.1,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,209.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS Rate,55,275.12,
BEDSIDE SWALLOWING EVAL,870565,CDM,444,RC,92610,HCPCS,Outpatient,,,75,52.5,,64.89,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,132.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS Rate,51,150,
VIDEO FLUOROSCOPIC SWALLOWING,870570,CDM,444,RC,92611,HCPCS,Outpatient,,,75,52.5,,84.79,100,,,fee schedule,100% Aetna Market fee schedule,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,150,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,75,100,,,Fee Schedule,100% of CMS OPPS Rate,51,150,
SPEECH PATHOLOGY EVALUATION,871000,CDM,444,RC,92506,HCPCS,Outpatient,,,300,210,YG,,,,,Other,Not Seperately Reimbusable,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,228,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,228,
BEDSIDE SWALLOWING EVALUATION,871020,CDM,444,RC,92610,HCPCS,Outpatient,,,300,210,,64.89,100,,,fee schedule,100% Aetna Market fee schedule,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,228,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,132.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,66.3,100,,,Fee Schedule,100% of CMS OPPS Rate,55,228,
VIDEO FLUOROSCOPIC SWALLOWING,871040,CDM,444,RC,92611,HCPCS,Outpatient,,,300,210,,84.79,100,,,fee schedule,100% Aetna Market fee schedule,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,228,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,170.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,85.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55,228,
EVALUATION OF SPEECH FLUENCY,871085,CDM,444,RC,92521,HCPCS,Outpatient,,,121,84.7,,109.99,100,,,fee schedule,100% Aetna Market fee schedule,82.28,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,91.96,76,,73.57,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,249.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,124.83,100,,,Fee Schedule,100% of CMS OPPS Rate,55,249.66,
EVAL OF SPEECH SOUND PRODUCTIO,871087,CDM,444,RC,92522,HCPCS,Outpatient,,,362,253.4,,92.33,100,,,fee schedule,100% Aetna Market fee schedule,246.16,68,,196.93,Percent of Total Billed Charges,68% of Total Billed Charges,275.12,76,,220.1,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,209.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,104.78,100,,,Fee Schedule,100% of CMS OPPS Rate,55,275.12,
EVAL OF SP SOUND PRO WITH EVAL,871090,CDM,444,RC,92523,HCPCS,Outpatient,,,742,519.4,,187.82,100,,,fee schedule,100% Aetna Market fee schedule,504.56,68,,403.65,Percent of Total Billed Charges,68% of Total Billed Charges,563.92,76,,451.14,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,427.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.98,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.98,100,,,Fee Schedule,100% of CMS OPPS Rate,55,563.92,
EVALUATION OF VOICE,871092,CDM,444,RC,92524,HCPCS,Outpatient,,,358,250.6,,90.96,100,,,fee schedule,100% Aetna Market fee schedule,243.44,68,,194.75,Percent of Total Billed Charges,68% of Total Billed Charges,272.08,76,,217.66,Percent of Total Billed Charges,76% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,206.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.35,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,103.35,100,,,Fee Schedule,100% of CMS OPPS Rate,55,272.08,
ER VISIT LEVEL 1,201103,CDM,450,RC,99281,HCPCS,Outpatient,,,209,146.3,,16.72,100,,,fee schedule,100% Aetna Market fee schedule,142.12,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,142.12,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,104.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,22.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.3,70,,117.04,Percent of Total Billed Charges,70% of Total Billed Charges,156.75,75,,125.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,108.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.02,255,
ER VISIT LEVEL 2,201106,CDM,450,RC,99282,HCPCS,Outpatient,,,384,268.8,,32.39,100,,,fee schedule,100% Aetna Market fee schedule,261.12,68,,208.9,Percent of Total Billed Charges,68% of Total Billed Charges,261.12,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,192,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,80.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268.8,70,,215.04,Percent of Total Billed Charges,70% of Total Billed Charges,288,75,,230.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,199.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,147.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate,80.4,288,
ER VISIT LEVEL 3,201109,CDM,450,RC,99283,HCPCS,Outpatient,,,670,469,,55.11,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,455.6,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,335,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,136.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,348.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,258.05,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,258.05,100,,,Fee Schedule,100% of CMS OPPS Rate,136.98,455.6,
ER VISIT LEVEL 4,201112,CDM,450,RC,99284,HCPCS,Outpatient,,,1090,763,,93.09,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,545,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,233.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,540.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,400.57,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.57,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,400.57,100,,,Fee Schedule,100% of CMS OPPS Rate,233.24,545,
ER VISIT LEVEL 5,201115,CDM,450,RC,99285,HCPCS,Outpatient,,,1580,1106,,135.18,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,11.2,Percent of Total Billed Charges,50% of Total Billed Charges,338.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS Rate,255,784.24,
ABD PARACENTESIS,201116,CDM,450,RC,49082,HCPCS,Outpatient,,,991,693.7,,66.77,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,495.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,137.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,137.76,1106.79,
SMP RPR F/E/E/N/L/M 5.1 - 7.5,201117,CDM,450,RC,12014,HCPCS,Outpatient,,,524,366.8,,64.72,100,,,fee schedule,100% Aetna Market fee schedule,356.32,68,,285.06,Percent of Total Billed Charges,68% of Total Billed Charges,356.32,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,262,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,145.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.8,70,,293.44,Percent of Total Billed Charges,70% of Total Billed Charges,393,75,,314.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,145.28,393,
CRITCL CARE 1ST 30-74 MIN,201118,CDM,450,RC,99291,HCPCS,Outpatient,,,2250,1575,,165.26,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,406.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1083.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,802.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,802.56,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,802.56,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1083.45,
CRITCL CARE EA ADD 30 MIN,201121,CDM,450,RC,X4011,HCPCS,Outpatient,,,350,245,,,,,,Other,Not Seperately Reimbusable,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,238,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,175,50,,107.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245,70,,196,Percent of Total Billed Charges,70% of Total Billed Charges,262.5,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,262.5,
REP COMP TRUCK 1.1 TO 2.5CM,201196,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REP COMP SCALP ARM LG 1.1-2.5C,201205,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REP COMP SCALP ARM LG 2.6-7.5C,201208,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,13.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REP COMP SCALP ARM LEG EA ADD,201209,CDM,450,RC,13122,HCPCS,Outpatient,,,335,234.5,,70.56,100,,,fee schedule,100% Aetna Market fee schedule,227.8,68,,182.24,Percent of Total Billed Charges,68% of Total Billed Charges,227.8,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,167.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,155.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.5,70,,187.6,Percent of Total Billed Charges,70% of Total Billed Charges,251.25,75,,201,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.3,255,
REP COMP FACE NCK GEN HND FT 1,201214,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
REP COMP FACE NCK GEN HND FT 2,201217,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
"LACER.COMP.EYE,NOSE UP TO 1.0C",201223,CDM,450,RC,X4014,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,68.68,68,,174.08,Percent of Total Billed Charges,68% of Total Billed Charges,50.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.7,70,,56.56,Percent of Total Billed Charges,70% of Total Billed Charges,75.75,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,255,
REP COMP LID NS EAR LIP 1.1 TO,201226,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REP COMP LID NS EAR LIP 2.6 TO,201229,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,74,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
LYR CLS SCLP TRNK AXL EXTR < 2,201235,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS SCLP TRNK AXL EXTR 2.6,201238,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,101.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS SCLP TRNK AXL EXTR 7.6,201241,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,10,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS SCLP TRNK AXL EXTR 12.,201244,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,12.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS NCK HND FT GENIT < 2.5,201247,CDM,450,RC,12041,HCPCS,Outpatient,,,706,494.2,,122.93,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,353,50,,130.8,Percent of Total Billed Charges,50% of Total Billed Charges,270.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,486.85,
LYR CLS NCK HND FT GENIT 2.6 T,201251,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS NCK HND FT GENIT 7.6 T,201253,CDM,450,RC,X4014,HCPCS,Outpatient,,,1449,1014.3,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,41.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
LYR CLS FACE < 2.5CM,201259,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,22.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS FACE 2.6 TO 5.0 CM,201262,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
LYR CLS FACE 5.1 TO 7.5 CM,201265,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,49.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
REP SMP SCP-NCK-AX-GN-TRNK-XTR,201271,CDM,450,RC,X4014,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,100.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
REP SMP SCP-NK-GN-TRNK XTRM 2.,201274,CDM,450,RC,12002,HCPCS,Outpatient,,,529,370.3,,50.88,100,,,fee schedule,100% Aetna Market fee schedule,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,113.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,113.02,396.75,
REP SMP SCP-NK-GN-TRNK-XTRM 7.,201277,CDM,450,RC,12004,HCPCS,Outpatient,,,529,370.3,,62.92,100,,,fee schedule,100% Aetna Market fee schedule,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,141.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,141.54,396.75,
REP SMP SCP-NCK-GN-TGRNK-XTRM,201280,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
REP SMP FACE < 2.5CM,201286,CDM,450,RC,12011,HCPCS,Outpatient,,,529,370.3,,47.65,100,,,fee schedule,100% Aetna Market fee schedule,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,106.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,106.58,396.75,
REP SMP FACE 2.6 TO 7.5 CM,201289,CDM,450,RC,X4014,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
REP SMP FACE 7.6 TO 12.5 CM,201292,CDM,450,RC,X4014,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,51.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
REP SMP FACE 12.6 TO 20.0 CM,201295,CDM,450,RC,12016,HCPCS,Outpatient,,,1815,1270.5,,111.57,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,247.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,247.16,650,
REP EXTEN TENDON HND WO GRPH,201297,CDM,450,RC,26410,HCPCS,Outpatient,,,4066,2846.2,,558.83,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,1098.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
WND CLOS W TISSUE ADHESIVE,201298,CDM,450,RC,X4014,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,34.68,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,34.68,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,25.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.7,70,,28.56,Percent of Total Billed Charges,70% of Total Billed Charges,38.25,75,,30.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.5,255,
REPR LAC 2.5CM OR LESS MOUTH,201300,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
I&D ABCESS SGL SIMP,201304,CDM,450,RC,X4014,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,12.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
THROMBOLYSIS CEREBRAL IV INFUS,201305,CDM,450,RC,37195,HCPCS,Outpatient,,,1017,711.9,,874.64,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,508.5,50,,58.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,255,508.5,
I&D ABCESS MULTI OR COMP,201307,CDM,450,RC,10061,HCPCS,Outpatient,,,942,659.4,,157.32,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,146.34,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,36,Percent of Total Billed Charges,50% of Total Billed Charges,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,486.85,
INCISION AND DRAINAGE POLONIDA,201310,CDM,450,RC,10080,HCPCS,Outpatient,,,1298,908.6,,89.71,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,61.41,Percent of Total Billed Charges,68% of Total Billed Charges,649,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,194.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,194.84,859.04,
I&D LEG ANK DEEP ABSCESS,201313,CDM,450,RC,X4014,HCPCS,Outpatient,,,7135,4994.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,423.78,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
PUNCT ASPIR ABSCESS HEMA BULLA,201316,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,350.82,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,60.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
DRAINAGE OF FINGER ABSCESS SIM,201319,CDM,450,RC,X4014,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,235.9,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
DRAIN FINGER ABSCESS COMP,201322,CDM,450,RC,X4014,HCPCS,Outpatient,,,4127,2888.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,132.54,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
INCIS PERIANAL ABSCESS SUPE,201325,CDM,450,RC,X4014,HCPCS,Outpatient,,,2235,1564.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,906.53,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,105.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
INCISION THROMBOSED HEMORRHOID,201327,CDM,450,RC,X4014,HCPCS,Outpatient,,,694,485.8,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,471.92,68,,279.07,Percent of Total Billed Charges,68% of Total Billed Charges,347,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,471.92,
I&D BART GL & ABSCESS,201328,CDM,450,RC,X4014,HCPCS,Outpatient,,,498,348.6,,,,,,Other,Not Seperately Reimbusable,338.64,68,,270.91,Percent of Total Billed Charges,68% of Total Billed Charges,338.64,68,,177.54,Percent of Total Billed Charges,68% of Total Billed Charges,249,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.6,70,,278.88,Percent of Total Billed Charges,70% of Total Billed Charges,373.5,75,,298.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249,373.5,
CONTROL NASAL HEMORR ANT SIMP,201337,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,395.81,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
CONTROL NASAL HEMORR ANT COMP,201343,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,279.68,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
CONTROL NASAL HEMORR POST INIT,201346,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,603.14,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,40,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
INTUBATION ENDOTRACHEAL EMERGE,201349,CDM,450,RC,31500,HCPCS,Outpatient,,,,,,147.31,100,,,fee schedule,100% Aetna Market fee schedule,,,,,Other,Not Seperately Reimbusable,,,,9.79,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,255,
REPLACEMENT OF GASTROMY TUBE,201350,CDM,450,RC,43760,HCPCS,Outpatient,,,211,147.7,,,,,,Other,Not Seperately Reimbusable,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,143.48,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,105.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.7,70,,118.16,Percent of Total Billed Charges,70% of Total Billed Charges,158.25,75,,126.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,255,
EXC BEN LES TNK EXTRM LS 4.0CM,201351,CDM,450,RC,11406,HCPCS,Outpatient,,,4117,2881.9,,212.65,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1979.55,
INCIS REMOV FB SUBQ SIMP,201358,CDM,450,RC,X4014,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,80.51,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
INCIS REMOV FB SUBQ COMP,201361,CDM,450,RC,X4014,HCPCS,Outpatient,,,4127,2888.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,264.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REMOVE FOREIGN BODY FR SUBCU,201362,CDM,450,RC,X4014,HCPCS,Outpatient,,,1738,1216.6,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
FOR.BODY MUSCLE SIMPLE FACILIT,201364,CDM,450,RC,X4014,HCPCS,Outpatient,,,4127,2888.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REPR BLODD VESSEL DIRECT LOWER,201365,CDM,450,RC,35226,HCPCS,Outpatient,,,1738,1216.6,,835.18,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1564.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1564.62,
FOR.BODY MUSCLE DEEP FACILITY,201367,CDM,450,RC,X4014,HCPCS,Outpatient,,,7135,4994.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,43.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
REMOVE FB MOUTH SIMPLE,201369,CDM,450,RC,40804,HCPCS,Outpatient,,,2285,1599.5,,101.53,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,37.2,Percent of Total Billed Charges,50% of Total Billed Charges,210.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1106.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,819.84,100,,,Fee Schedule,100% of CMS OPPS Rate,210.06,1106.79,
REMOVE FB INTRANASAL,201370,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,9.79,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
REMOVE FOREIGN BODY PHARYNX,201373,CDM,450,RC,X4014,HCPCS,Outpatient,,,1044,730.8,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,522,50,,38.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,522,
REMOVE FB EYE CONJ SUPER,201376,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
REMOVE FB EYE CONJ EMBED,201379,CDM,450,RC,X4014,HCPCS,Outpatient,,,1044,730.8,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,522,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,522,
REMOVE FB EAR WO ANES,201382,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,134.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
REMOVE IMPACTED CERUMEN,201385,CDM,450,RC,X4014,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,114.24,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,84,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.6,70,,94.08,Percent of Total Billed Charges,70% of Total Billed Charges,126,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,255,
REMOVE IMPACTED CERUMEN IRRIGA,201388,CDM,450,RC,69209,HCPCS,Outpatient,,,165,115.5,,13.3,100,,,fee schedule,100% Aetna Market fee schedule,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,112.2,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,82.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,27.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,70,,92.4,Percent of Total Billed Charges,70% of Total Billed Charges,123.75,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,27.52,255,
REPL GASTRO TUBE PERQ WO GUID,201389,CDM,450,RC,43762,HCPCS,Outpatient,,,705,493.5,,33.81,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,352.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,71.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,71.58,477,
MANUAL THERAPY,201390,CDM,450,RC,97535,HCPCS,Outpatient,,,97,67.9,,25.44,100,,,fee schedule,100% Aetna Market fee schedule,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,65.96,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,48.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,60.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.9,70,,54.32,Percent of Total Billed Charges,70% of Total Billed Charges,72.75,75,,58.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,40.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,255,
REMOVE FB CORN WO SLIT,201391,CDM,450,RC,65220,HCPCS,Outpatient,,,1091,763.7,,42.42,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,545.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,77.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,77.68,545.5,
SMPL RPR SCP-NCK-GN-TRNK-XTRM,201392,CDM,450,RC,12006,HCPCS,Outpatient,,,958,670.6,,100.98,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,479,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,223.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,223.9,486.85,
AVULSION NAIL PLATE SGL SIMP,201394,CDM,450,RC,X4014,HCPCS,Outpatient,,,550,385,,,,,,Other,Not Seperately Reimbusable,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,374,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,275,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,400,
TUBE THORACOSTOMY,201396,CDM,450,RC,32551,HCPCS,Outpatient,,,4308,3015.6,,162.84,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,295.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1955.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1448.47,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1955.43,
EVACUATN OF SUBUNGUAL HEMATOMA,201397,CDM,450,RC,X4014,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
I&D VULVA PERINEAL ABS,201399,CDM,450,RC,56405,HCPCS,Outpatient,,,812,568.4,,107.76,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,406,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,391.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,236.06,477,
NAILS NAILBED RECONSTR. FACILI,201400,CDM,450,RC,X4014,HCPCS,Outpatient,,,4647,3252.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
ARTHRO ASPIR INJ MAJOR JOINTS,201415,CDM,450,RC,X4014,HCPCS,Outpatient,,,742,519.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,30.46,Percent of Total Billed Charges,68% of Total Billed Charges,371,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
ARTHRO ASPIR INJ INTERMED JNTS,201417,CDM,450,RC,20605,HCPCS,Outpatient,,,742,519.4,,33.79,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,371,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,69.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.96,477,
ASPIRATION OF JOINT OR BURSA,201420,CDM,450,RC,20610,HCPCS,Outpatient,,,742,519.4,,41.14,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,371,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,86.18,477,
RHYTHM ECG 1 TO 3 LEADS W INTR,201429,CDM,450,RC,93040,HCPCS,Outpatient,,,150,105,,11.5,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,102,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,75,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,23.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,70,,84,Percent of Total Billed Charges,70% of Total Billed Charges,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.86,255,
EAR PULSE OX SGL DETER,201434,CDM,450,RC,94760,HCPCS,Outpatient,,,120,84,,2.11,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,81.6,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,60,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,70,,67.2,Percent of Total Billed Charges,70% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,255,
EAR PULSE OX MULT DETER,201435,CDM,450,RC,94761,HCPCS,Outpatient,,,120,84,,3.03,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,81.6,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,60,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,6.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,70,,67.2,Percent of Total Billed Charges,70% of Total Billed Charges,90,75,,72,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.92,255,
INIT TRT 1ST DEGREE BURN,201442,CDM,450,RC,X4011,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
DRSS DBRID PRTL THKNS BURN SM,201445,CDM,450,RC,16020,HCPCS,Outpatient,,,530,371,,46.55,100,,,fee schedule,100% Aetna Market fee schedule,360.4,68,,288.32,Percent of Total Billed Charges,68% of Total Billed Charges,360.4,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,265,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,103.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,397.5,75,,318,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,103.64,397.5,
DRSS DBRID BURN PRTL THKNS MED,201448,CDM,450,RC,X4011,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,359.72,68,,287.78,Percent of Total Billed Charges,68% of Total Billed Charges,359.72,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,264.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,396.75,75,,317.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,396.75,
DRSS DBRID BURN PRTL THCKNS LG,201451,CDM,450,RC,X4011,HCPCS,Outpatient,,,942,659.4,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,471,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
DEBRIDEMENT OF SKIN-FACILITY F,201455,CDM,450,RC,11040,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,91.12,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,67,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.8,70,,75.04,Percent of Total Billed Charges,70% of Total Billed Charges,100.5,75,,80.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,255,
CLTXMNT TMJ DISLOCATN,201460,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX PROX HUM FX WO M,201465,CDM,450,RC,23600,HCPCS,Outpatient,,,647,452.9,,290.83,100,,,fee schedule,100% Aetna Market fee schedule,439.96,68,,351.97,Percent of Total Billed Charges,68% of Total Billed Charges,439.96,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,323.5,50,,63.6,Percent of Total Billed Charges,50% of Total Billed Charges,599.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,599.4,
CLTX SHOULDER DISLOC,201466,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX ELBOW DISLOC WO ANES,201469,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX ELBOW DISLOC W ANES,201470,CDM,450,RC,X4014,HCPCS,Outpatient,,,3940,2758,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,100.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
CLTX CARPOMETA DISLOC W MANIP,201472,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,82.14,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX METCRPL DISLOC,201475,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,109.34,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX DISTL FIB FX W MAN,201476,CDM,450,RC,27788,HCPCS,Outpatient,,,726,508.2,,354.55,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,363,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,733.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,733.9,
CLTX INTER JNT WO ANE,201478,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX RADIAL HEAD SUBL,201479,CDM,450,RC,24640,HCPCS,Outpatient,,,647,452.9,,73.74,100,,,fee schedule,100% Aetna Market fee schedule,439.96,68,,351.97,Percent of Total Billed Charges,68% of Total Billed Charges,439.96,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,323.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,150.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,150.8,439.96,
CLTX PATELLAR DISLOC,201481,CDM,450,RC,27560,HCPCS,Outpatient,,,632,442.4,,310.27,100,,,fee schedule,100% Aetna Market fee schedule,429.76,68,,343.81,Percent of Total Billed Charges,68% of Total Billed Charges,429.76,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,316,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,652.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,652.2,
CLTX INTRPHLGL DISLOC,201484,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,314.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTXX CLAVICAL FX WO M,201494,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,54.4,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLOSD TRT BIMALL ANK W MAN,201495,CDM,450,RC,27810,HCPCS,Outpatient,,,3940,2758,,391.77,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,817.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
TRT TAIL BONE FRACTURE,201496,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
DLTX FX FINGR THUMB W/O MAN,201498,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTXMENT FEMUR FRAC,201500,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX FX GREAT TOE WO MAN,201502,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,360.13,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLSD TRT HUMERL TUBEROS FX WO,201504,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX METCRPL FX SINGL WO MAN,201505,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX MET FX W/O MAN,201506,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX METCRPL FX W MAN EA,201507,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,58.75,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTXMNT NASAL BONE FRAC,201508,CDM,450,RC,21310,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CHANGE OF CYSTOSTOMY TUBE SIMP,201509,CDM,450,RC,51705,HCPCS,Outpatient,,,305,213.5,,45.48,100,,,fee schedule,100% Aetna Market fee schedule,207.4,68,,165.92,Percent of Total Billed Charges,68% of Total Billed Charges,207.4,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,152.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.5,70,,170.8,Percent of Total Billed Charges,70% of Total Billed Charges,228.75,75,,183,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,301.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,223.52,100,,,Fee Schedule,100% of CMS OPPS Rate,97.34,301.75,
CLTX PHLNGL FX NOT DISTAL W/MA,201510,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX PHLNGL DIS W MANI,201511,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX FINGER FX MTCRPHLNGL/IPHA,201512,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,26.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX FX PHALANX W MAN,201513,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,182.78,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX RAD & ULNA SHF WO MAN,201514,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX DS RD FX I NC ULN ST W MA,201515,CDM,450,RC,25605,HCPCS,Outpatient,,,3940,2758,,470.41,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,973.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
FRACTURE RIB FACILITY FEE,201516,CDM,450,RC,X4014,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.5,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,63.75,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,255,
CLTX SCAPULAR FRAC,201518,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
FRACTURE SKULL FACILITY FEE,201520,CDM,450,RC,X4014,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.5,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,63.75,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,255,
CLTX FX PHALANX WO MAN,201521,CDM,450,RC,28510,HCPCS,Outpatient,,,647,452.9,,108.04,100,,,fee schedule,100% Aetna Market fee schedule,439.96,68,,351.97,Percent of Total Billed Charges,68% of Total Billed Charges,439.96,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,323.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,226.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,439.96,
CLTX TIB FX PROX WO M,201522,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,10.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
FRACTURE ULNA FACILITY FEE,201524,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,271.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
FRACTURE VERTEBRAL PROCESS FAC,201526,CDM,450,RC,X4014,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,57.8,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.5,70,,47.6,Percent of Total Billed Charges,70% of Total Billed Charges,63.75,75,,51,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,255,
CLTX FRACTURE WRIST W MAN,201528,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
CLTX FX GREAT TOE W MAN,201529,CDM,450,RC,28495,HCPCS,Outpatient,,,647,452.9,,135.55,100,,,fee schedule,100% Aetna Market fee schedule,439.96,68,,351.97,Percent of Total Billed Charges,68% of Total Billed Charges,439.96,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,323.5,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,281.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,439.96,
CAST APPLICATION SHORT,201541,CDM,450,RC,X4011,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,68.68,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,50.5,50,,174.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.7,70,,56.56,Percent of Total Billed Charges,70% of Total Billed Charges,75.75,75,,60.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.5,255,
CAST APPLICATION LONG FACILITY,201544,CDM,450,RC,X4011,HCPCS,Outpatient,,,171,119.7,,,,,,Other,Not Seperately Reimbusable,116.28,68,,93.02,Percent of Total Billed Charges,68% of Total Billed Charges,116.28,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,85.5,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,70,,95.76,Percent of Total Billed Charges,70% of Total Billed Charges,128.25,75,,102.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.5,255,
CAST REMOVAL SHORT FACILITY FE,201547,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST REMOVAL LONG FACILITY FEE,201550,CDM,450,RC,X4011,HCPCS,Outpatient,,,705,493.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,97.38,Percent of Total Billed Charges,68% of Total Billed Charges,352.5,50,,255.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST LEG LONG FACILITY FEE,201553,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST LEG SHORT FACILITY FEE,201556,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST ARM LONG FACILITY FEE,201559,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST ARM SHORT FACILITY FEE,201562,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
CAST HANGING FACILITY FEE,201565,CDM,450,RC,X4011,HCPCS,Outpatient,,,262,183.4,,,,,,Other,Not Seperately Reimbusable,178.16,68,,142.53,Percent of Total Billed Charges,68% of Total Billed Charges,178.16,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,131,50,,235.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.4,70,,146.72,Percent of Total Billed Charges,70% of Total Billed Charges,196.5,75,,157.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131,255,
CAST BODY FACILITY FEE,201568,CDM,450,RC,X4011,HCPCS,Outpatient,,,262,183.4,,,,,,Other,Not Seperately Reimbusable,178.16,68,,142.53,Percent of Total Billed Charges,68% of Total Billed Charges,178.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,131,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.4,70,,146.72,Percent of Total Billed Charges,70% of Total Billed Charges,196.5,75,,157.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131,255,
CAST-CYLINDER-FACILITY FEE,201570,CDM,450,RC,X4011,HCPCS,Outpatient,,,707,494.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,28.29,Percent of Total Billed Charges,68% of Total Billed Charges,353.5,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,477,
APPLY LONG ARM SPLINT,201580,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
SPLINT LONG ARM CHILD FACILITY,201583,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
APPLY SHORT ARM SPLINT STATIC,201586,CDM,450,RC,X4011,HCPCS,Outpatient,,,327,228.9,,,,,,Other,Not Seperately Reimbusable,222.36,68,,177.89,Percent of Total Billed Charges,68% of Total Billed Charges,222.36,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,163.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,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,245.25,75,,196.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.5,255,
SPLINT SHORT ARM CHILD FACILIT,201589,CDM,450,RC,X4011,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.5,255,
APPLIC OF FINGER SPLINT STATIC,201592,CDM,450,RC,X4011,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,114.24,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,84,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.6,70,,94.08,Percent of Total Billed Charges,70% of Total Billed Charges,126,75,,100.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,255,
SPLINT LONG LEG ADULT FACILITY,201595,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,27.74,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
APPLY LONG LEG SPLINT,201598,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
LIGATN OR BIOPSY TEMPORAL ARTE,201600,CDM,450,RC,37609,HCPCS,Outpatient,,,4127,2888.9,,206.24,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,60,Percent of Total Billed Charges,50% of Total Billed Charges,382.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1979.55,
APPLY SHORT LEG SPLINT,201601,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
SPLINT SHORT LEG CHILD FACILIT,201604,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
STRAPPINGS SHOULDER (EG VELPEA,201613,CDM,450,RC,29240,HCPCS,Outpatient,,,319,223.3,,16.9,100,,,fee schedule,100% Aetna Market fee schedule,216.92,68,,173.54,Percent of Total Billed Charges,68% of Total Billed Charges,216.92,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,159.5,50,,260.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.3,70,,178.64,Percent of Total Billed Charges,70% of Total Billed Charges,239.25,75,,191.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,34.12,255,
STRAPPING KNEE,201614,CDM,450,RC,29530,HCPCS,Outpatient,,,327,228.9,,16.6,100,,,fee schedule,100% Aetna Market fee schedule,222.36,68,,177.89,Percent of Total Billed Charges,68% of Total Billed Charges,222.36,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,163.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,34.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.9,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,245.25,75,,196.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,34.12,255,
STRAPPING ANKLE AND/OR FT,201615,CDM,450,RC,29540,HCPCS,Outpatient,,,401,280.7,,16.23,100,,,fee schedule,100% Aetna Market fee schedule,272.68,68,,218.14,Percent of Total Billed Charges,68% of Total Billed Charges,272.68,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,200.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,33.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.7,70,,224.56,Percent of Total Billed Charges,70% of Total Billed Charges,300.75,75,,240.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,33.04,300.75,
STRAPPING ELBOW OR WRIST,201616,CDM,450,RC,X4011,HCPCS,Outpatient,,,100,70,,,,,,Other,Not Seperately Reimbusable,68,68,,54.4,Percent of Total Billed Charges,68% of Total Billed Charges,68,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,50,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,75,75,,60,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,255,
STRAPPING HND OR FINGER,201617,CDM,450,RC,29280,HCPCS,Outpatient,,,100,70,,18.05,100,,,fee schedule,100% Aetna Market fee schedule,68,68,,54.4,Percent of Total Billed Charges,68% of Total Billed Charges,68,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,50,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,38.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70,70,,56,Percent of Total Billed Charges,70% of Total Billed Charges,75,75,,60,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,255,
STRAPPING TOES,201618,CDM,450,RC,29550,HCPCS,Outpatient,,,165,115.5,,10.32,100,,,fee schedule,100% Aetna Market fee schedule,112.2,68,,89.76,Percent of Total Billed Charges,68% of Total Billed Charges,112.2,68,,164.83,Percent of Total Billed Charges,68% of Total Billed Charges,82.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,21.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.5,70,,92.4,Percent of Total Billed Charges,70% of Total Billed Charges,123.75,75,,99,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.36,255,
STRAPPING UNNA BOOT,201619,CDM,450,RC,X4011,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,274.72,68,,219.78,Percent of Total Billed Charges,68% of Total Billed Charges,274.72,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,202,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,282.8,70,,226.24,Percent of Total Billed Charges,70% of Total Billed Charges,303,75,,242.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,303,
NEEDLE PLACE INTRAOSS INFUSE,201620,CDM,450,RC,36680,HCPCS,Outpatient,,,1091,763.7,,59.76,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,545.5,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,114.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,114.16,545.5,
CARDIOVERSION EXTERNAL,201622,CDM,450,RC,92960,HCPCS,Outpatient,,,1609,1126.3,,99.45,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,428.13,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,201.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,794.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.78,794.63,
INSERT NON TUNNEL CV CATH 5+,201628,CDM,450,RC,36556,HCPCS,Outpatient,,,3281,2296.7,,85.21,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,160.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3891.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,2882.85,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,3891.84,
IV INFUS HYDRAT INIT 31 MIN TO,201629,CDM,450,RC,96360,HCPCS,Outpatient,,,350,245,,31.12,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,238,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,175,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,57.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245,70,,196,Percent of Total Billed Charges,70% of Total Billed Charges,262.5,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,57.14,262.5,
IV INFUS HYDRATE EA ADDL HR,201630,CDM,450,RC,96361,HCPCS,Outpatient,,,114,79.8,,11.74,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,22.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,22.08,255,
INTRO CATH SUP INFER VENA CAVA,201631,CDM,450,RC,X4014,HCPCS,Outpatient,,,212,148.4,,,,,,Other,Not Seperately Reimbusable,144.16,68,,115.33,Percent of Total Billed Charges,68% of Total Billed Charges,144.16,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,106,50,,6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.4,70,,118.72,Percent of Total Billed Charges,70% of Total Billed Charges,159,75,,127.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106,255,
IV INFUS THER PROPH DX INIT HR,201632,CDM,450,RC,96365,HCPCS,Outpatient,,,350,245,,61.42,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,238,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,175,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,109.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245,70,,196,Percent of Total Billed Charges,70% of Total Billed Charges,262.5,75,,210,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,109.78,262.5,
IV INFUS THX PROPH DX EA ADDL,201633,CDM,450,RC,96366,HCPCS,Outpatient,,,114,79.8,,19.23,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,6.4,Percent of Total Billed Charges,50% of Total Billed Charges,36.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,36.64,255,
INTRO NEEDLE INTRACATH VEIN,201634,CDM,450,RC,X4011,HCPCS,Outpatient,,,41,28.7,,,,,,Other,Not Seperately Reimbusable,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,27.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,20.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.7,70,,22.96,Percent of Total Billed Charges,70% of Total Billed Charges,30.75,75,,24.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,255,
IV INFUS ADDL SEQ TO 1 HR,201635,CDM,450,RC,96367,HCPCS,Outpatient,,,181,126.7,,27.48,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,123.08,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,90.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.7,70,,101.36,Percent of Total Billed Charges,70% of Total Billed Charges,135.75,75,,108.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,50.46,255,
IV INFUS CONCURRENT,201636,CDM,450,RC,96368,HCPCS,Outpatient,,,390,273,,18.6,100,,,fee schedule,100% Aetna Market fee schedule,265.2,68,,212.16,Percent of Total Billed Charges,68% of Total Billed Charges,265.2,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,195,50,,38,Percent of Total Billed Charges,50% of Total Billed Charges,35.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273,70,,218.4,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,75,,234,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.4,292.5,
THORACOSTOMY TUBE FACILITY FEE,201637,CDM,450,RC,X4014,HCPCS,Outpatient,,,600,420,,,,,,Other,Not Seperately Reimbusable,408,68,,326.4,Percent of Total Billed Charges,68% of Total Billed Charges,408,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,300,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,408,
INJECT THER DX INTRA ARTERIAL,201638,CDM,450,RC,96373,HCPCS,Outpatient,,,551,385.7,,16.46,100,,,fee schedule,100% Aetna Market fee schedule,374.68,68,,299.74,Percent of Total Billed Charges,68% of Total Billed Charges,374.68,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,275.5,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,33.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,33.68,400,
INJ THER DX INTRV S/I DRUG,201639,CDM,450,RC,96374,HCPCS,Outpatient,,,551,385.7,,35.73,100,,,fee schedule,100% Aetna Market fee schedule,374.68,68,,299.74,Percent of Total Billed Charges,68% of Total Billed Charges,374.68,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,275.5,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,64.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,261.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,193.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.74,400,
IV PUSH EA ADDL SEQ DRUG,201640,CDM,450,RC,96375,HCPCS,Outpatient,,,114,79.8,,14.51,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,27.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,27.32,255,
EA ADD IVP SAME RX > 30 MIN,201641,CDM,450,RC,96376,HCPCS,Outpatient,,,390,273,,9.29,100,,,fee schedule,100% Aetna Market fee schedule,265.2,68,,212.16,Percent of Total Billed Charges,68% of Total Billed Charges,265.2,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,195,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,273,70,,218.4,Percent of Total Billed Charges,70% of Total Billed Charges,292.5,75,,234,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195,292.5,
IRR IMP VEN ACC DEV DRUG DELIV,201642,CDM,450,RC,96523,HCPCS,Outpatient,,,171,119.7,,24.96,100,,,fee schedule,100% Aetna Market fee schedule,116.28,68,,93.02,Percent of Total Billed Charges,68% of Total Billed Charges,116.28,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,85.5,50,,103.6,Percent of Total Billed Charges,50% of Total Billed Charges,43.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.7,70,,95.76,Percent of Total Billed Charges,70% of Total Billed Charges,128.25,75,,102.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,255,
ADMIN INFLUENZA VIRUS VACCINE,201643,CDM,450,RC,G0008,HCPCS,Outpatient,,,114,79.8,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,255,
ADMIN PNEUMOCOCCAL VACCINE,201644,CDM,450,RC,G0009,HCPCS,Outpatient,,,114,79.8,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,57,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.8,70,,63.84,Percent of Total Billed Charges,70% of Total Billed Charges,85.5,75,,68.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,255,
INJECT THER DX SUBCU OR IM,201645,CDM,450,RC,96372,HCPCS,Outpatient,,,181,126.7,,13.09,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,123.08,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,90.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.7,70,,101.36,Percent of Total Billed Charges,70% of Total Billed Charges,135.75,75,,108.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,255,
INCIS OF WINDPIPE EMERGENCY,201646,CDM,450,RC,31603,HCPCS,Outpatient,,,3837,2685.9,,333.86,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1862.03,
INJ ANSTH TRIGEMINAL NERVE,201647,CDM,450,RC,64400,HCPCS,Outpatient,,,785,549.5,,43.2,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,392.5,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,97.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,97.28,477,
THORANCENTESIS INIT/SUBS,201649,CDM,450,RC,32555,HCPCS,Outpatient,,,1860,1302,,114.28,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,205.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,767.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,205.98,767.02,
"THORAC NDL, CATH ASPN PLRL SPC",201650,CDM,450,RC,32554,HCPCS,Outpatient,,,1860,1302,,93.09,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,46.8,Percent of Total Billed Charges,50% of Total Billed Charges,167.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,767.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167.94,767.02,
INJ ANSTH OTH PERIPHERAL NERVE,201651,CDM,450,RC,64450,HCPCS,Outpatient,,,1875,1312.5,,36.36,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,368.83,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,844.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,625.45,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,844.35,
NG TUBE LAVAGE/ASPIRATION FACI,201652,CDM,450,RC,X4011,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,95.88,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,70.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.7,70,,78.96,Percent of Total Billed Charges,70% of Total Billed Charges,105.75,75,,84.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,255,
"GI INTUBATE, ASPIR W/WO LAVAGE",201653,CDM,450,RC,43753,HCPCS,Outpatient,,,759,531.3,,20.11,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,379.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,41.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,41.42,477,
TRANSTRACHEAL INTRO NDL DILAT,201655,CDM,450,RC,X4011,HCPCS,Outpatient,,,4108,2875.6,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,237.18,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,642.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
EWOL TUBE PLACEMENT FACILITY F,201658,CDM,450,RC,X4011,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,95.88,68,,76.7,Percent of Total Billed Charges,68% of Total Billed Charges,95.88,68,,34.82,Percent of Total Billed Charges,68% of Total Billed Charges,70.5,50,,26.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.7,70,,78.96,Percent of Total Billed Charges,70% of Total Billed Charges,105.75,75,,84.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.5,255,
SPINAL PUNCTURE LUMBAR DIAGNOS,201661,CDM,450,RC,X4014,HCPCS,Outpatient,,,1796,1257.2,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
BIOPSY OF SKIN-SINGLE LESION-F,201663,CDM,450,RC,X4014,HCPCS,Outpatient,,,422,295.4,,,,,,Other,Not Seperately Reimbusable,286.96,68,,229.57,Percent of Total Billed Charges,68% of Total Billed Charges,286.96,68,,347.07,Percent of Total Billed Charges,68% of Total Billed Charges,211,50,,18.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.4,70,,236.32,Percent of Total Billed Charges,70% of Total Billed Charges,316.5,75,,253.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211,316.5,
BREAST BIOPSY FACILITY FEE,201664,CDM,450,RC,X4014,HCPCS,Outpatient,,,4127,2888.9,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,650,
PARACENTESIS FACILITY FEE,201667,CDM,450,RC,X4014,HCPCS,Outpatient,,,401,280.7,,,,,,Other,Not Seperately Reimbusable,272.68,68,,218.14,Percent of Total Billed Charges,68% of Total Billed Charges,272.68,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,200.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.7,70,,224.56,Percent of Total Billed Charges,70% of Total Billed Charges,300.75,75,,240.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.5,300.75,
INSERT NON INDWELL BLAD CATH,201670,CDM,450,RC,51701,HCPCS,Outpatient,,,327,228.9,,23.04,100,,,fee schedule,100% Aetna Market fee schedule,222.36,68,,177.89,Percent of Total Billed Charges,68% of Total Billed Charges,222.36,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,163.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.9,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,245.25,75,,196.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,48.68,255,
INSRT TEMP INDWL BLAD CATH SIM,201671,CDM,450,RC,51702,HCPCS,Outpatient,,,327,228.9,,22.77,100,,,fee schedule,100% Aetna Market fee schedule,222.36,68,,177.89,Percent of Total Billed Charges,68% of Total Billed Charges,222.36,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,163.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.9,70,,183.12,Percent of Total Billed Charges,70% of Total Billed Charges,245.25,75,,196.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,48.04,255,
INSERT TEMP BLAD CATH COMPL,201673,CDM,450,RC,X4011,HCPCS,Outpatient,,,408,285.6,,,,,,Other,Not Seperately Reimbusable,277.44,68,,221.95,Percent of Total Billed Charges,68% of Total Billed Charges,277.44,68,,320.42,Percent of Total Billed Charges,68% of Total Billed Charges,204,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.6,70,,228.48,Percent of Total Billed Charges,70% of Total Billed Charges,306,75,,244.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204,306,
BLOOD COMP DERIV ADMIN PER DAY,201675,CDM,450,RC,36430,HCPCS,Outpatient,,,1164,814.8,,37.87,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,70.72,Percent of Total Billed Charges,68% of Total Billed Charges,582,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,72.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,530.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,392.61,100,,,Fee Schedule,100% of CMS OPPS Rate,72.84,582,
OB CARE VAGINAL DELIVERY ONLY,201676,CDM,450,RC,59409,HCPCS,Outpatient,,,8039,5627.3,,610.76,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,6.8,Percent of Total Billed Charges,50% of Total Billed Charges,1537.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3817.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,255,3817.2,
DELIVERY PLACENTA,201677,CDM,450,RC,59414,HCPCS,Outpatient,,,7084,4958.8,,68.41,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,174.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3817.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,2827.56,100,,,Fee Schedule,100% of CMS OPPS Rate,174.4,3817.2,
CARDIOPULMONARY RESUSCITATN,201688,CDM,450,RC,92950,HCPCS,Outpatient,,,757,529.9,,170.07,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,378.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,349.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,255,477,
NASAL/OROGASTRIC W/TUBE PLMT,202222,CDM,450,RC,43752,HCPCS,Outpatient,,,125,87.5,,36.72,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,85,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,62.5,50,,23.2,Percent of Total Billed Charges,50% of Total Billed Charges,75.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.5,70,,70,Percent of Total Billed Charges,70% of Total Billed Charges,93.75,75,,75,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.35,100,,,Fee Schedule,100% of CMS OPPS Rate,62.5,486.48,
REMOVE EXT HEM GROUPS 2+,202223,CDM,450,RC,46250,HCPCS,Outpatient,,,1523,1066.1,,293.17,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,596.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,3428.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,2539.44,100,,,Fee Schedule,100% of CMS OPPS Rate,255,3428.24,
TREAT METATARSAL FRACTURE,202224,CDM,450,RC,28470,HCPCS,Outpatient,,,715,500.5,,187.6,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,357.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,386.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,477,
RPR S/N/AX/GEN/TRNK >30.0 CM,202225,CDM,450,RC,12007,HCPCS,Outpatient,,,744,520.8,,125.81,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,372,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,277.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,181.06,477,
RMVL SKIN TAGS UP TO&INC 15,202227,CDM,450,RC,11200,HCPCS,Outpatient,,,294,205.8,,64.52,100,,,fee schedule,100% Aetna Market fee schedule,199.92,68,,159.94,Percent of Total Billed Charges,68% of Total Billed Charges,199.92,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,147,50,,12,Percent of Total Billed Charges,50% of Total Billed Charges,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,205.8,70,,164.64,Percent of Total Billed Charges,70% of Total Billed Charges,220.5,75,,176.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,140.48,255,
DBRDMT SUBQ TIS 1ST 20SQCM/<,202228,CDM,450,RC,11042,HCPCS,Outpatient,,,411,287.7,,51.54,100,,,fee schedule,100% Aetna Market fee schedule,279.48,68,,223.58,Percent of Total Billed Charges,68% of Total Billed Charges,279.48,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,205.5,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.7,70,,230.16,Percent of Total Billed Charges,70% of Total Billed Charges,308.25,75,,246.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,113.98,486.85,
FRACTURE-DISTALPHALANGEAL W/MA,501511,CDM,450,RC,X4014,HCPCS,Outpatient,,,675,472.5,,,,,,Other,Not Seperately Reimbusable,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,459,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,337.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,459,
MOD SED SAME PHYS/QHP 5/>YRS,550642,CDM,450,RC,99152,HCPCS,Outpatient,,,102,71.4,,11.6,100,,,fee schedule,100% Aetna Market fee schedule,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,69.36,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,51,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,23.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.4,70,,57.12,Percent of Total Billed Charges,70% of Total Billed Charges,76.5,75,,61.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.16,255,
MOD SED SAME PHYS/QHP EA,550644,CDM,450,RC,99153,HCPCS,Outpatient,,,102,71.4,,9.73,100,,,fee schedule,100% Aetna Market fee schedule,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,69.36,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,51,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,20.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.4,70,,57.12,Percent of Total Billed Charges,70% of Total Billed Charges,76.5,75,,61.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.16,255,
DRAINAGE OF ABSCESS OF PALATE,893396,CDM,450,RC,42000,HCPCS,Outpatient,,,611,427.7,,97.71,100,,,fee schedule,100% Aetna Market fee schedule,415.48,68,,332.38,Percent of Total Billed Charges,68% of Total Billed Charges,415.48,68,,57.12,Percent of Total Billed Charges,68% of Total Billed Charges,305.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,202.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,202.76,415.48,
INCIS ISCHIO ABSCESS,893402,CDM,450,RC,46040,HCPCS,Outpatient,,,3177,2223.9,,390.34,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,797.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1440.83,
INJ TRIGGER POINT 1 TO 2 MUSCL,893437,CDM,450,RC,20552,HCPCS,Outpatient,,,800,560,,34.37,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,400,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,69.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.7,477,
CLTX DSTL RDL FX/EPIPHYSL SEP,893493,CDM,450,RC,25605,HCPCS,Outpatient,,,4268,2987.6,,470.41,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,973.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
THORAC NDL CATH ASN PLRL SPC W,893495,CDM,450,RC,32554,HCPCS,Outpatient,,,1656,1159.2,,93.09,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,167.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,767.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,568.15,100,,,Fee Schedule,100% of CMS OPPS Rate,167.94,767.02,
DEBRIDEMENT OPEN WOUND 20 SQ C,893497,CDM,450,RC,97597,HCPCS,Outpatient,,,550,385,,33.45,100,,,fee schedule,100% Aetna Market fee schedule,374,68,,299.2,Percent of Total Billed Charges,68% of Total Billed Charges,374,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,275,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,67.72,400,
RPR INTERMED F/E/E/N/L&/MUC 7.,893515,CDM,450,RC,12054,HCPCS,Outpatient,,,1059,741.3,,187.11,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,529.5,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,413.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,529.5,
SIMPLE RPR F/E/E/N/L/M 12.6 TO,893517,CDM,450,RC,12016,HCPCS,Outpatient,,,1815,1270.5,,111.57,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,169.6,Percent of Total Billed Charges,50% of Total Billed Charges,247.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,247.16,650,
TRACHEOSTOMY EMERGENCY PROC TR,893549,CDM,450,RC,31603,HCPCS,Outpatient,,,4145,2901.5,,333.86,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,21.6,Percent of Total Billed Charges,50% of Total Billed Charges,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1862.03,
DRAINAGE OF GUM LESION,893561,CDM,450,RC,41800,HCPCS,Outpatient,,,345,241.5,,138.84,100,,,fee schedule,100% Aetna Market fee schedule,234.6,68,,187.68,Percent of Total Billed Charges,68% of Total Billed Charges,234.6,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,172.5,50,,39.2,Percent of Total Billed Charges,50% of Total Billed Charges,280.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.5,70,,193.2,Percent of Total Billed Charges,70% of Total Billed Charges,258.75,75,,207,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,115.53,280.1,
CLSD TX SHOULDER DISLC W/MANIP,893568,CDM,450,RC,23655,HCPCS,Outpatient,,,4268,2987.6,,376.09,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,19.6,Percent of Total Billed Charges,50% of Total Billed Charges,772.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
CLD TRT DISLOC HIP REQ ANES,893601,CDM,450,RC,27252,HCPCS,Outpatient,,,4268,2987.6,,691.18,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,140.9,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,102,Percent of Total Billed Charges,50% of Total Billed Charges,1419,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255,1962.35,
CLSD TX CLAVICULAR FRACTURE W/,893610,CDM,450,RC,23500,HCPCS,Outpatient,,,621,434.7,,204.75,100,,,fee schedule,100% Aetna Market fee schedule,422.28,68,,337.82,Percent of Total Billed Charges,68% of Total Billed Charges,422.28,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,310.5,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,434.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,434.72,
I & D ABSCESS EAR SIMPLE,893628,CDM,450,RC,69000,HCPCS,Outpatient,,,1907,1334.9,,110.32,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,650,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,233.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,233.14,859.04,
MOD SED SAME PHYS/QHP <5 YRS,893630,CDM,450,RC,99151,HCPCS,Outpatient,,,102,71.4,,23.01,100,,,fee schedule,100% Aetna Market fee schedule,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,69.36,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,51,50,,35.2,Percent of Total Billed Charges,50% of Total Billed Charges,45.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.4,70,,57.12,Percent of Total Billed Charges,70% of Total Billed Charges,76.5,75,,61.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.52,255,
REMOVE FB EYE CONJ SUPER,893632,CDM,450,RC,65205,HCPCS,Outpatient,,,345,241.5,,30.11,100,,,fee schedule,100% Aetna Market fee schedule,234.6,68,,187.68,Percent of Total Billed Charges,68% of Total Billed Charges,234.6,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,172.5,50,,27.6,Percent of Total Billed Charges,50% of Total Billed Charges,54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.5,70,,193.2,Percent of Total Billed Charges,70% of Total Billed Charges,258.75,75,,207,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,54,258.75,
RPR LAC 2.5 CM/< PST ONE-THRD,893636,CDM,450,RC,41251,HCPCS,Outpatient,,,623,436.1,,164.11,100,,,fee schedule,100% Aetna Market fee schedule,423.64,68,,338.91,Percent of Total Billed Charges,68% of Total Billed Charges,423.64,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,311.5,50,,16.8,Percent of Total Billed Charges,50% of Total Billed Charges,342.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,298.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,220.91,100,,,Fee Schedule,100% of CMS OPPS Rate,220.91,423.64,
DRSS DBRID BURN PRTL THCKNS LG,893641,CDM,450,RC,16030,HCPCS,Outpatient,,,1119,783.3,,112.77,100,,,fee schedule,100% Aetna Market fee schedule,443,68,,354.4,Percent of Total Billed Charges,68% of Total Billed Charges,477,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,559.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,248.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,248.62,559.5,
IRR IMP VEN ACC DEV DRUG DELIV,893642,CDM,450,RC,96523,HCPCS,Outpatient,,,172,120.4,,24.96,100,,,fee schedule,100% Aetna Market fee schedule,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,116.96,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,86,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,43.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.4,70,,96.32,Percent of Total Billed Charges,70% of Total Billed Charges,129,75,,103.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,255,
CLTX PHAL FX WO MAN,893654,CDM,450,RC,26720,HCPCS,Outpatient,,,621,434.7,,173.1,100,,,fee schedule,100% Aetna Market fee schedule,422.28,68,,337.82,Percent of Total Billed Charges,68% of Total Billed Charges,422.28,68,,16.32,Percent of Total Billed Charges,68% of Total Billed Charges,310.5,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,360.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,422.28,
CLTX FX GREAT TOE WO MAN,893678,CDM,450,RC,28490,HCPCS,Outpatient,,,621,434.7,,113.04,100,,,fee schedule,100% Aetna Market fee schedule,422.28,68,,337.82,Percent of Total Billed Charges,68% of Total Billed Charges,422.28,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,310.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,233.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370,70,,296,Percent of Total Billed Charges,70% of Total Billed Charges,400,75,,320,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,287.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,255,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,213.28,100,,,Fee Schedule,100% of CMS OPPS Rate,213.28,422.28,
DUIFFUSE CAPACITY,850347,CDM,460,RC,94729,HCPCS,Outpatient,,,182,127.4,,8.23,100,,,fee schedule,100% Aetna Market fee schedule,123.76,68,,99.01,Percent of Total Billed Charges,68% of Total Billed Charges,138.32,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,91,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,82.42,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.42,138.32,
PFT RESID VOL VIA NITRO WSHOUT,850445,CDM,460,RC,94727,HCPCS,Outpatient,,,436,305.2,,11.09,100,,,fee schedule,100% Aetna Market fee schedule,296.48,68,,237.18,Percent of Total Billed Charges,68% of Total Billed Charges,331.36,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,218,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,56.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,331.36,
BRONCHOSPASM EVAL SPIROMETRY,852333,CDM,460,RC,94060,HCPCS,Outpatient,,,840,588,,9.5,100,,,fee schedule,100% Aetna Market fee schedule,571.2,68,,456.96,Percent of Total Billed Charges,68% of Total Billed Charges,638.4,76,,80.26,Percent of Total Billed Charges,76% of Total Billed Charges,420,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,638.4,
PROLONGED POSTEXPOSURE EVAL OF,852334,CDM,460,RC,94070,HCPCS,Outpatient,,,293,205.1,TC,25.98,100,,,fee schedule,100% Aetna Market fee schedule,199.24,68,,159.39,Percent of Total Billed Charges,68% of Total Billed Charges,222.68,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,146.5,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,61.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,61.9,383.23,
RESPIRATORY FLOW VOLUME LOOP,852343,CDM,460,RC,94375,HCPCS,Outpatient,,,840,588,,13.31,100,,,fee schedule,100% Aetna Market fee schedule,571.2,68,,456.96,Percent of Total Billed Charges,68% of Total Billed Charges,638.4,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,420,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,638.4,
EAR PULSE OX SGL DETER,852354,CDM,460,RC,94760,HCPCS,Outpatient,,,28,19.6,,2.11,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,105,
PULM STRS TST INC HRT RAT OX O,852369,CDM,460,RC,94618,HCPCS,Outpatient,,,348,243.6,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,236.64,68,,189.31,Percent of Total Billed Charges,68% of Total Billed Charges,264.48,76,,275.42,Percent of Total Billed Charges,76% of Total Billed Charges,174,50,,15.2,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,264.48,
EAR PULSE OX SGL DETER,201433,CDM,460,RC,94760,HCPCS,Outpatient,,,62,43.4,,2.11,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,20.8,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,105,
SCREENING  #1,760310,CDM,460,RC,94010,HCPCS,Outpatient,,,234,163.8,,7.58,100,,,fee schedule,100% Aetna Market fee schedule,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,33.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,33.24,190.72,
SCREENING PRE&POST#2,760315,CDM,460,RC,94060,HCPCS,Outpatient,,,334,233.8,,9.5,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,133.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,383.23,
DFS PFT,850345,CDM,460,RC,94060,HCPCS,Outpatient,,,234,163.8,,9.5,100,,,fee schedule,100% Aetna Market fee schedule,159.12,68,,127.3,Percent of Total Billed Charges,68% of Total Billed Charges,177.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,49.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,383.23,
APNEA MTR PER DAY,850427,CDM,460,RC,94772,HCPCS,Outpatient,,,289,202.3,,107.5,100,,,fee schedule,100% Aetna Market fee schedule,196.52,68,,157.22,Percent of Total Billed Charges,68% of Total Billed Charges,219.64,76,,175.71,Percent of Total Billed Charges,76% of Total Billed Charges,144.5,50,,115.6,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,,,,,Other,Not Seperately Reimbusable,436.28,100,,,Fee Schedule,100% of MO Medicaid Rate,654.41,135,,,Fee Schedule,135% of CMS OPPS Rate,445.01,102,,,Fee Schedule,102% MO Medicaid rate,484.75,100,,,Fee Schedule,100% of CMS OPPS rate,445.01,102,,,Fee Schedule,102% of MO Medicaid rate,436.28,100,,,Fee Schedule,100% of MO Medicaid rate,484.75,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,436.28,100,,,Fee Schedule,100% of MO Medicaid Rate,484.75,100,,,Fee Schedule,100% of CMS OPPS Rate,105,654.41,
INCENTIVE SPIRO.,850450,CDM,460,RC,94200,HCPCS,Outpatient,,,47,32.9,,2.8,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,105,
INCENTIVE SPIRO.S-UP,850500,CDM,460,RC,94200,HCPCS,Outpatient,,,61,42.7,,2.8,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,105,
PEAK FLOW,851381,CDM,460,RC,94200,HCPCS,Outpatient,,,61,42.7,,2.8,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,105,
PULSE OXIMETRY;SINGLE DETERMIN,852303,CDM,460,RC,94760,HCPCS,Outpatient,,,39,27.3,,2.11,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,15.6,Percent of Total Billed Charges,50% of Total Billed Charges,4.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.64,105,
"VITAL CAPACITY, TOTAL",852335,CDM,460,RC,94150,HCPCS,Outpatient,,,68,47.6,,3.45,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,34,190.72,
PEAK FLOW INITIAL,852336,CDM,460,RC,94200,HCPCS,Outpatient,,,61,42.7,,2.8,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,105,
FUNCTIONAL RESIDUAL CAPACITY/R,852337,CDM,460,RC,94240,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
"EXPIRED GAS COLLECTION,QUANT;S",852338,CDM,460,RC,94250,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,105,
THORACIC GAS VOLUME,852339,CDM,460,RC,94260,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
NITROGEN WASHOUT,852340,CDM,460,RC,94350,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
DETERM RESISTANCE TO AIRFLOW,852341,CDM,460,RC,94360,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
DETERM AIRWAY CLOSING VOLUME;S,852342,CDM,460,RC,94370,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
BREATHING RESPONSE TO CO2,852344,CDM,460,RC,94400,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
BREATHING RESPONSE TO HYPOXIA,852345,CDM,460,RC,94450,HCPCS,Outpatient,,,120,84,,16.52,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,104.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,60,190.72,
PULMONARY STRESS TEST;SIMPLE,852346,CDM,460,RC,94620,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
PULMONARY STRESS TEST;COMPLEX,852347,CDM,460,RC,94621,HCPCS,Outpatient,,,593,415.1,,63.79,100,,,fee schedule,100% Aetna Market fee schedule,403.24,68,,322.59,Percent of Total Billed Charges,68% of Total Billed Charges,450.68,76,,360.54,Percent of Total Billed Charges,76% of Total Billed Charges,296.5,50,,237.2,Percent of Total Billed Charges,50% of Total Billed Charges,151.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,105,450.68,
OXYGEN UPTAKE REST/EXERCISE;DI,852348,CDM,460,RC,94680,HCPCS,Outpatient,,,267,186.9,,11.98,100,,,fee schedule,100% Aetna Market fee schedule,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,71.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,71.62,202.92,
OXYGEN UPTAKE;INCLUDING CO2 OU,852349,CDM,460,RC,94681,HCPCS,Outpatient,,,267,186.9,,9.16,100,,,fee schedule,100% Aetna Market fee schedule,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,66.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,66.48,383.23,
OXYGEN UPTAKE;REST;INDIRECT,852350,CDM,460,RC,94690,HCPCS,Outpatient,,,120,84,,3.45,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,48,Percent of Total Billed Charges,50% of Total Billed Charges,77.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,49.79,105,
CARBON MONOXIDE DIFFUSING CAPA,852351,CDM,460,RC,94720,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,105,
MEMBRANE DIFFUSION CAPACITY,852352,CDM,460,RC,94725,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
PULMONARY COMPLIANCE STUDY;ANY,852353,CDM,460,RC,94750,HCPCS,Outpatient,,,267,186.9,,,,,,Other,Not Seperately Reimbusable,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,202.92,
PULSE OXIMETRY;MULTIPLE DETERM,852355,CDM,460,RC,94761,HCPCS,Outpatient,,,53,37.1,,3.03,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,6.92,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.92,105,
PULSE OXIMETRY;CONTINUOUS OVER,852356,CDM,460,RC,94762,HCPCS,Outpatient,,,158,110.6,,23.84,100,,,fee schedule,100% Aetna Market fee schedule,107.44,68,,85.95,Percent of Total Billed Charges,68% of Total Billed Charges,120.08,76,,96.06,Percent of Total Billed Charges,76% of Total Billed Charges,79,50,,63.2,Percent of Total Billed Charges,50% of Total Billed Charges,43.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,129.69,102,,,Fee Schedule,102% MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,129.69,102,,,Fee Schedule,102% of MO Medicaid rate,127.15,100,,,Fee Schedule,100% of MO Medicaid rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,105,100,,,Case Rate,Pays based on per visit rate,127.15,100,,,Fee Schedule,100% of MO Medicaid Rate,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,43.52,190.72,
CARDIOVERSION ELECTRIC EXT,323453,CDM,480,RC,92960,HCPCS,Outpatient,,,140,98,,99.45,100,,,fee schedule,100% Aetna Market fee schedule,95.2,68,,76.16,Percent of Total Billed Charges,68% of Total Billed Charges,106.4,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,70,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,201.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,794.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,588.62,100,,,Fee Schedule,100% of CMS OPPS Rate,70,794.63,
CODE 33,851832,CDM,480,RC,92950,HCPCS,Outpatient,,,1058,740.6,,170.07,100,,,fee schedule,100% Aetna Market fee schedule,719.44,68,,575.55,Percent of Total Billed Charges,68% of Total Billed Charges,804.08,76,,643.26,Percent of Total Billed Charges,76% of Total Billed Charges,529,50,,423.2,Percent of Total Billed Charges,50% of Total Billed Charges,349.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,150,804.08,
ECHO 2D,890178,CDM,480,RC,93307,HCPCS,Outpatient,,,1284,898.8,TC,40.81,100,,,fee schedule,100% Aetna Market fee schedule,873.12,68,,698.5,Percent of Total Billed Charges,68% of Total Billed Charges,975.84,76,,780.67,Percent of Total Billed Charges,76% of Total Billed Charges,642,50,,513.6,Percent of Total Billed Charges,50% of Total Billed Charges,161.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,150,975.84,
DOPPLER ECHOCARDIOGRAM,890180,CDM,480,RC,93320,HCPCS,Outpatient,,,428,299.6,,16.48,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,325.28,76,,260.22,Percent of Total Billed Charges,76% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,57.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.26,325.28,
DOPPLER COLOR FLOW,890181,CDM,480,RC,93325,HCPCS,Outpatient,,,322,225.4,,2.86,100,,,fee schedule,100% Aetna Market fee schedule,218.96,68,,175.17,Percent of Total Billed Charges,68% of Total Billed Charges,244.72,76,,195.78,Percent of Total Billed Charges,76% of Total Billed Charges,161,50,,128.8,Percent of Total Billed Charges,50% of Total Billed Charges,34.88,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.88,244.72,
ECHOCARDIOGRAPHY COMPLETE GLOB,890185,CDM,480,RC,93306,HCPCS,Outpatient,,,1480,1036,,64.28,100,,,fee schedule,100% Aetna Market fee schedule,1006.4,68,,805.12,Percent of Total Billed Charges,68% of Total Billed Charges,1124.8,76,,899.84,Percent of Total Billed Charges,76% of Total Billed Charges,740,50,,592,Percent of Total Billed Charges,50% of Total Billed Charges,221.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.05,100,,,Fee Schedule,100% of MO Medicaid Rate,673.58,135,,,Fee Schedule,135% of CMS OPPS Rate,458.03,102,,,Fee Schedule,102% MO Medicaid rate,498.94,100,,,Fee Schedule,100% of CMS OPPS rate,458.03,102,,,Fee Schedule,102% of MO Medicaid rate,449.05,100,,,Fee Schedule,100% of MO Medicaid rate,498.94,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,449.05,100,,,Fee Schedule,100% of MO Medicaid Rate,498.94,100,,,Fee Schedule,100% of CMS OPPS Rate,150,1124.8,
ECHOCARDIOGRAPHY LIMITED,890186,CDM,480,RC,93308,HCPCS,Outpatient,,,1249,874.3,,23.12,100,,,fee schedule,100% Aetna Market fee schedule,849.32,68,,679.46,Percent of Total Billed Charges,68% of Total Billed Charges,949.24,76,,759.39,Percent of Total Billed Charges,76% of Total Billed Charges,624.5,50,,499.6,Percent of Total Billed Charges,50% of Total Billed Charges,127.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,127.68,949.24,
ECHO LIMITED/FOLLOW UP,890187,CDM,480,RC,93308,HCPCS,Outpatient,,,125,87.5,,23.12,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,127.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,150,100,,,Case Rate,Pays based on per visit rate,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,62.5,299.18,
ARTHROCENSTESIS,5502,CDM,490,RC,20610,HCPCS,Outpatient,,,112,78.4,,41.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,164,Percent of Total Billed Charges,50% of Total Billed Charges,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,56,1444.4,
ASPIRATION OF GANGLION CYST,5505,CDM,490,RC,20612,HCPCS,Outpatient,,,101,70.7,,37.43,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,166.4,Percent of Total Billed Charges,50% of Total Billed Charges,77.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,361.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,267.87,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,1444.4,
BIOPSY OF SKIN-SINGLE LESION,5520,CDM,490,RC,11100,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,1444.4,
BIOPSY OF SKIN-SEPARATE/ADD LE,5525,CDM,490,RC,11101,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,1444.4,
DEBRIDEMENT OF INFECTED SKIN,5529,CDM,490,RC,11000,HCPCS,Outpatient,,,80,56,,23.94,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,28,Percent of Total Billed Charges,50% of Total Billed Charges,52.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,40,1444.4,
DEST LES-LASER/ELECTRO/CRYO- L,5530,CDM,490,RC,17000,HCPCS,Outpatient,,,107,74.9,,46.8,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,101.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,53.5,1444.4,
DEST LES-LASER/ELECTRO/CRYO- L,5535,CDM,490,RC,17003,HCPCS,Outpatient,,,21,14.7,,1.78,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,1444.4,
DEST CONJUNCTION VASC < 10 SQ,5540,CDM,490,RC,17106,HCPCS,Outpatient,,,613,429.1,,234.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,306.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,513.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST CONJUNCTION VASC 10.0 - 5,5545,CDM,490,RC,17107,HCPCS,Outpatient,,,1092,764.4,,305.26,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,546,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,667.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST FLAT WART/MOLLUSCUM/MILOA,5550,CDM,490,RC,17110,HCPCS,Outpatient,,,147,102.9,,56.64,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,210.37,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,125.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,1444.4,
DEST MAL LES-TRUNK/ARM/LEG-0.5,5560,CDM,490,RC,17260,HCPCS,Outpatient,,,147,102.9,,60.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,131,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,1444.4,
DEST MAL LES-TRUNK/ARM/LEG-1.1,5565,CDM,490,RC,17262,HCPCS,Outpatient,,,227,158.9,,93.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,205.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-TRUNK/ARM/LEG-3.1,5570,CDM,490,RC,17263,HCPCS,Outpatient,,,253,177.1,,103.82,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,159.3,Percent of Total Billed Charges,76% of Total Billed Charges,126.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,228.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-SCALP/NECK/ETC-0.,5575,CDM,490,RC,17270,HCPCS,Outpatient,,,201,140.7,,80.13,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,178.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-SCALP/NECK/ETC-0.,5580,CDM,490,RC,17271,HCPCS,Outpatient,,,214,149.8,,88.63,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,60.19,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,195.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-SCALP/NECK/ETC-3.,5585,CDM,490,RC,17274,HCPCS,Outpatient,,,340,238,,142.34,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,170,50,,102.4,Percent of Total Billed Charges,50% of Total Billed Charges,312.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-FACE/EAR/ETC-0.5C,5590,CDM,490,RC,17280,HCPCS,Outpatient,,,181,126.7,,73.07,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,30,Percent of Total Billed Charges,50% of Total Billed Charges,161.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,90.5,1444.4,
DEST MAL LES-FACE/EAR/ETC-0.6,5595,CDM,490,RC,17281,HCPCS,Outpatient,,,240,168,,100.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,120,50,,33.2,Percent of Total Billed Charges,50% of Total Billed Charges,220.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEST MAL LES-FACE/EAR/ETC-3.1,5600,CDM,490,RC,17284,HCPCS,Outpatient,,,407,284.9,,169.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,203.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,371.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
EXC BENIGN LES-TRUNK/LEG/ARM-0,5610,CDM,490,RC,11400,HCPCS,Outpatient,,,186,130.2,,71.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,49.25,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,155.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,93,1444.4,
EXC BENIGN LES-TRUNK/ARM/LEG-0,5615,CDM,490,RC,11401,HCPCS,Outpatient,,,220,154,,90.17,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,110,50,,2.4,Percent of Total Billed Charges,50% of Total Billed Charges,195.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
EXC BENIGN LES-TRUNK/ARM/LEG-2,5620,CDM,490,RC,11403,HCPCS,Outpatient,,,280,196,,126.56,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,140,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,277.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,140,1444.4,
EXC BENIGN LES-TRUNK/ARM/LEG-3,5625,CDM,490,RC,11404,HCPCS,Outpatient,,,319,223.3,,140.16,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,159.5,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,306.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.5,1979.55,
EXC BENIGN LES-TRUNK/ARM/LEG-O,5630,CDM,490,RC,11406,HCPCS,Outpatient,,,394,275.8,,212.65,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,139.23,Percent of Total Billed Charges,76% of Total Billed Charges,197,50,,20.4,Percent of Total Billed Charges,50% of Total Billed Charges,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,197,1979.55,
EXC BENIGN LES-SCALP/NECK/ETC-,5635,CDM,490,RC,11420,HCPCS,Outpatient,,,181,126.7,,70.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,28.4,Percent of Total Billed Charges,50% of Total Billed Charges,152.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,90.5,1979.55,
EXC BENIGN LES-FACE/EAR/EYELID,5640,CDM,490,RC,11440,HCPCS,Outpatient,,,465,325.5,,89.71,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,232.5,50,,19.2,Percent of Total Billed Charges,50% of Total Billed Charges,195.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.98,1444.4,
EXC BENIGN LES-FACE/EAR/ETC-OV,5645,CDM,490,RC,11446,HCPCS,Outpatient,,,572,400.4,,274.07,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,286,50,,103.6,Percent of Total Billed Charges,50% of Total Billed Charges,595.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,286,3469.39,
"EXCISION FASCIOTOMY, PALMAR",5650,CDM,490,RC,26040,HCPCS,Outpatient,,,424,296.8,,289.06,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,212,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,595.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1962.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1453.6,100,,,Fee Schedule,100% of CMS OPPS Rate,212,1962.35,
EXC MAL LES-TRUNK/ARM/LEG-0.5C,5660,CDM,490,RC,11600,HCPCS,Outpatient,,,261,182.7,,104.31,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,130.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,227.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,130.5,1444.4,
EXC MAL LES-TRUNK/ARM/LEG-0.6,5665,CDM,490,RC,11601,HCPCS,Outpatient,,,293,205.1,,126.61,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,146.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,275.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,1444.4,
EXC MAL LES-TRUNK/ARM/LEG-2.1,5670,CDM,490,RC,11603,HCPCS,Outpatient,,,347,242.9,,164.43,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,173.5,50,,140.8,Percent of Total Billed Charges,50% of Total Billed Charges,359.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,173.5,1444.4,
EXC MAL LES-TRUNK/ARM/LEG-3.1,5675,CDM,490,RC,11604,HCPCS,Outpatient,,,467,326.9,,181.35,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,486.4,Percent of Total Billed Charges,76% of Total Billed Charges,233.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,396.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,1444.4,
EXC MAL LES-TRUNK/ARM/LEG-OVER,5680,CDM,490,RC,11606,HCPCS,Outpatient,,,500,350,,271.88,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,250,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,594.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,250,1979.55,
EXC MAL LES-SCALP/NECK/ETC-0.5,5685,CDM,490,RC,11620,HCPCS,Outpatient,,,247,172.9,,104.9,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,123.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,229.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.5,1979.55,
EXC MAL LES-SCALP/NECK/ETC-0.6,5690,CDM,490,RC,11621,HCPCS,Outpatient,,,293,205.1,,127.2,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,146.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,277.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,146.5,1444.4,
EXC MAL LES-SCALP/NECK/ETC-2.1,5695,CDM,490,RC,11623,HCPCS,Outpatient,,,394,275.8,,178.43,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,197,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,389.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,197,1979.55,
EXC MAL LES-SCALP/NECK/ETC-3.1,5700,CDM,490,RC,11624,HCPCS,Outpatient,,,453,317.1,,203.21,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,108.22,Percent of Total Billed Charges,76% of Total Billed Charges,226.5,50,,20,Percent of Total Billed Charges,50% of Total Billed Charges,444.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,226.5,1979.55,
EXC MAL LES-SCALP/NECK/ETC-OVE,5705,CDM,490,RC,11626,HCPCS,Outpatient,,,600,420,,250.6,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,300,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,546.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,300,3469.39,
EXC MAL LES-FACE/EAR/NOSE/ETC-,5710,CDM,490,RC,11640,HCPCS,Outpatient,,,261,182.7,,107.81,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,130.5,50,,391.2,Percent of Total Billed Charges,50% of Total Billed Charges,235.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,130.5,1444.4,
EXC MAL LES-FACE/EAR/NOSE/ETC-,5715,CDM,490,RC,11641,HCPCS,Outpatient,,,340,238,,132.2,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,170,50,,61.6,Percent of Total Billed Charges,50% of Total Billed Charges,288.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,170,1444.4,
EXC MAL LES-FACE/EAR/NOSE/ETC-,5720,CDM,490,RC,11643,HCPCS,Outpatient,,,460,322,,193.95,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,230,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,423.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,230,1979.55,
EXC MAL LES-FACE/EAR/NOSE/ETC-,5725,CDM,490,RC,11644,HCPCS,Outpatient,,,580,406,,241.21,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,239.55,Percent of Total Billed Charges,76% of Total Billed Charges,290,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,526.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,290,1979.55,
I & D OF ABCESS-SIMPLE,5728,CDM,490,RC,10060,HCPCS,Outpatient,,,104,72.8,,89.65,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,310.08,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,196.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,52,1444.4,
EXC MAL LES-FACE/EAR/NOSE/ETC-,5730,CDM,490,RC,11646,HCPCS,Outpatient,,,786,550.2,,334.67,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,198.21,Percent of Total Billed Charges,76% of Total Billed Charges,393,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,730.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,393,3469.39,
PARING/CUTTING BENIGN LESION-1,5740,CDM,490,RC,11055,HCPCS,Outpatient,,,68,47.6,,13.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,1444.4,
ABI,5741,CDM,490,RC,93922,HCPCS,Outpatient,,,103,72.1,,11.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,51.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,121.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,51.5,1444.4,
PARING/CUTTING BENIGN LESION-2,5745,CDM,490,RC,11056,HCPCS,Outpatient,,,85,59.5,,19.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,53.5,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,42.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,42.16,1444.4,
PARING/CUTTING BENIGN LESION-5,5750,CDM,490,RC,11057,HCPCS,Outpatient,,,107,74.9,,24.87,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,55.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,53.5,1444.4,
REMOVAL OF FOREIGN BODY-HAND,5755,CDM,490,RC,20520,HCPCS,Outpatient,,,319,223.3,,133.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,159.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,275.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,159.5,1979.55,
REMOVAL OF SKIN TAGS-UP TO 15,5760,CDM,490,RC,11200,HCPCS,Outpatient,,,120,84,,64.52,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,60,1444.4,
REMOVAL OF SKIN TAGS-ADDTL 10,5765,CDM,490,RC,11201,HCPCS,Outpatient,,,35,24.5,,14.06,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,30.4,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,1444.4,
SHAVING OF TRUNK/ARM/LEG-0.5CM,5770,CDM,490,RC,11300,HCPCS,Outpatient,,,101,70.7,,29.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,63.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,1444.4,
SHAVING OF TRUNK/ARM/LEG-0.6 T,5775,CDM,490,RC,11301,HCPCS,Outpatient,,,131,91.7,,43.73,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,65.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,96.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,65.5,1444.4,
SHAVING OF TRUNK/ARM/LEG-1.1 T,5780,CDM,490,RC,11302,HCPCS,Outpatient,,,154,107.8,,51.34,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,23.6,Percent of Total Billed Charges,50% of Total Billed Charges,111.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,77,1444.4,
SHAVING OF TRUNK/ARM/LEG-OVER,5785,CDM,490,RC,11303,HCPCS,Outpatient,,,186,130.2,,60.49,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,3790.88,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,133.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,93,1444.4,
SHAVING OF SCALP/NECK/FEET-0.5,5790,CDM,490,RC,11305,HCPCS,Outpatient,,,102,71.4,,33.02,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,71.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,51,1444.4,
SHAVING OF SCALP/NECK/FEET-0.6,5795,CDM,490,RC,11306,HCPCS,Outpatient,,,141,98.7,,42.39,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,70.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,92.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,70.5,1444.4,
SHAVING OF SCALP/NECK/FEET-1.1,5800,CDM,490,RC,11307,HCPCS,Outpatient,,,160,112,,54.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,7.6,Percent of Total Billed Charges,50% of Total Billed Charges,117.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80,1444.4,
SHAVING OF SCALP/NECK/FEET-OVE,5805,CDM,490,RC,11308,HCPCS,Outpatient,,,194,135.8,,61.08,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,11.55,Percent of Total Billed Charges,76% of Total Billed Charges,97,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,133.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,97,1444.4,
SHAVING FACE/EAR/EYELID/NOSE-0,5810,CDM,490,RC,11310,HCPCS,Outpatient,,,114,79.8,,39.01,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,144.7,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,85.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,57,1444.4,
SHAVING FACE/EAR/EYELID/NOSE-0,5815,CDM,490,RC,11311,HCPCS,Outpatient,,,149,104.3,,53.42,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,74.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,117.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,74.5,1444.4,
SHAVING FACE/EAR/EYELID/NOSE-1,5820,CDM,490,RC,11312,HCPCS,Outpatient,,,173,121.1,,63.14,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,139.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,86.5,1444.4,
SHAVING FACE/EAR/EYELID/NOSE-O,5825,CDM,490,RC,11313,HCPCS,Outpatient,,,227,158.9,,82.4,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,180.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
WEDGE EXCISION SKN/NAIL,5830,CDM,490,RC,11765,HCPCS,Outpatient,,,152,106.4,,73.12,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,71.74,Percent of Total Billed Charges,76% of Total Billed Charges,76,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,172.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,76,1444.4,
INSERT URINE CATH SIMPLE,550256,CDM,490,RC,51701,HCPCS,Outpatient,,,55,38.5,,23.04,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,9.6,Percent of Total Billed Charges,50% of Total Billed Charges,48.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,27.5,1444.4,
INSERT URINE CATH COMPLEX,550258,CDM,490,RC,51703,HCPCS,Outpatient,,,246,172.2,,68.03,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,123,50,,162,Percent of Total Billed Charges,50% of Total Billed Charges,144.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,190.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,141.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,141.27,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DECLOT VASCULAR ACCESS DEVICE,550259,CDM,490,RC,36593,HCPCS,Outpatient,,,35,24.5,,32.5,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,136.8,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,59.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,306.3,100,,,Fee Schedule,100% of CMS OPPS Rate,17.5,1444.4,
DEBRIDEMENT-OPEN WOUND-FIRST 2,8500,CDM,490,RC,97597,HCPCS,Outpatient,,,275,192.5,,33.45,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,137.5,50,,110,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,67.72,1444.4,
DEBRIDEMENT-OPEN WOUND-EA ADD,8501,CDM,490,RC,97598,HCPCS,Outpatient,,,92,64.4,,23.23,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,46,50,,36.8,Percent of Total Billed Charges,50% of Total Billed Charges,46.9,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,1444.4,
DEBRIDEMENT-SUBSQ-FIRST 20 SQ,8502,CDM,490,RC,11042,HCPCS,Outpatient,,,426,298.2,,51.54,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,213,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEBRIDEMENT-SUBQ-EA ADDTL 20 S,8503,CDM,490,RC,11045,HCPCS,Outpatient,,,426,298.2,,22.53,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,213,50,,170.4,Percent of Total Billed Charges,50% of Total Billed Charges,48.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.18,1444.4,
DEBRIDEMENT-MUSCLE/FASCIA-FIRS,8504,CDM,490,RC,11043,HCPCS,Outpatient,,,752,526.4,,131.95,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,376,50,,300.8,Percent of Total Billed Charges,50% of Total Billed Charges,290.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,766.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,568.02,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DEBRIDEMENT-MUSCLE/FASCIA-EA A,8505,CDM,490,RC,11046,HCPCS,Outpatient,,,236,165.2,,47.62,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,118,50,,94.4,Percent of Total Billed Charges,50% of Total Billed Charges,104.32,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
DEBRIDEMENT-BONE-FIRST 20 SQ C,8506,CDM,490,RC,11044,HCPCS,Outpatient,,,1045,731.5,,193.18,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,522.5,50,,418,Percent of Total Billed Charges,50% of Total Billed Charges,427.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,1979.55,
DEBRIDEMENT-BONE-EA ADDTL 20 S,8507,CDM,490,RC,11047,HCPCS,Outpatient,,,348,243.6,,83.29,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,174,50,,139.2,Percent of Total Billed Charges,50% of Total Billed Charges,184.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,1444.4,
NPWT < 50 SQ CM,8508,CDM,490,RC,97605,HCPCS,Outpatient,,,80,56,,23.15,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,46.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,40,1444.4,
NPWT > 50 SQ CM,8509,CDM,490,RC,97606,HCPCS,Outpatient,,,64,44.8,,25.37,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,32,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,32,1444.4,
DRESSING AND/OR DEBRIDE PART T,8510,CDM,490,RC,16020,HCPCS,Outpatient,,,169,118.3,,46.55,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,84.5,50,,67.6,Percent of Total Billed Charges,50% of Total Billed Charges,103.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,84.5,1444.4,
DRESSING AND/OR DEBRIDE PART T,8511,CDM,490,RC,16025,HCPCS,Outpatient,,,312,218.4,,95.43,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,156,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,209.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
DRESSING AND/OR DEBRIDE PART T,8512,CDM,490,RC,16030,HCPCS,Outpatient,,,312,218.4,,112.77,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,156,50,,124.8,Percent of Total Billed Charges,50% of Total Billed Charges,248.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
I&D ABCESS-SINGLE OR SIMPLE,8513,CDM,490,RC,10060,HCPCS,Outpatient,,,146,102.2,,89.65,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,73,50,,58.4,Percent of Total Billed Charges,50% of Total Billed Charges,196.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,73,1444.4,
I&D ABCESS-MULTIPLE OR COMPLIC,8514,CDM,490,RC,10061,HCPCS,Outpatient,,,255,178.5,,157.32,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,127.5,50,,102,Percent of Total Billed Charges,50% of Total Billed Charges,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1444.4,
PARING/CUT BENIGN HYPERKERATON,8515,CDM,490,RC,11055,HCPCS,Outpatient,,,231,161.7,,13.86,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,115.5,50,,92.4,Percent of Total Billed Charges,50% of Total Billed Charges,29.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,1444.4,
PARING/CUT BENIGN HYPERKERATON,8516,CDM,490,RC,11056,HCPCS,Outpatient,,,85,59.5,,19.24,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,34,Percent of Total Billed Charges,50% of Total Billed Charges,42.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,42.16,1444.4,
PARING/CUT BENIGN HYPERKERATON,8517,CDM,490,RC,11057,HCPCS,Outpatient,,,107,74.9,,24.87,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,Percent of Total Billed Charges,50% of Total Billed Charges,55.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,53.5,1444.4,
BIOPSY SKIN-ONE LESION,8518,CDM,490,RC,11100,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,53.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,1444.4,
BIOPSY SKIN-EA ADDTL LESION,8519,CDM,490,RC,11101,HCPCS,Outpatient,,,53,37.1,,,,,,Other,Not Seperately Reimbusable,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,1444.4,
BIOPSY BONE-TROCAR OR NEEDLE-S,8520,CDM,490,RC,20220,HCPCS,Outpatient,,,1045,731.5,,79.06,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,522.5,50,,418,Percent of Total Billed Charges,50% of Total Billed Charges,163.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1979.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1466.33,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,1979.55,
BIOPSY BONE-OPEN-SUPERFICIAL,8521,CDM,490,RC,20240,HCPCS,Outpatient,,,2046,1432.2,,128.8,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1023,50,,818.4,Percent of Total Billed Charges,50% of Total Billed Charges,265.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3469.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,563,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,2569.92,100,,,Fee Schedule,100% of CMS OPPS Rate,265.84,3469.39,
APPLY MULTILAYER COMP LOWER LE,8522,CDM,490,RC,29581,HCPCS,Outpatient,,,125,87.5,,25.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,50,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,1444.4,
APPLY BILATERAL MULTI COMP LOW,8523,CDM,490,RC,29581,HCPCS,Outpatient,,,288,201.6,,25.1,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,144,50,,115.2,Percent of Total Billed Charges,50% of Total Billed Charges,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,142.51,100,,,Fee Schedule,100% of CMS OPPS Rate,50.88,1444.4,
CHEM CAUT OF GRANULATION TISSU,8524,CDM,490,RC,17250,HCPCS,Outpatient,,,47,32.9,,31.98,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,18.8,Percent of Total Billed Charges,50% of Total Billed Charges,69.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,23.5,1444.4,
DEBRIDEMENT NAILS 1-5,8528,CDM,490,RC,11720,HCPCS,Outpatient,,,106,74.2,,11.8,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,42.4,Percent of Total Billed Charges,50% of Total Billed Charges,27.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,27.24,1444.4,
APPLICATION OF FINGER SPLINT,291300,CDM,510,RC,29130,HCPCS,Outpatient,,,92,64.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,46,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,55.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,46,177.57,
I & D ABSCESS SGL SIMP,1006000,CDM,521,RC,10060,HCPCS,Outpatient,,,337,235.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.5,50,,134.8,Percent of Total Billed Charges,50% of Total Billed Charges,196.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,168.5,244.43,
I & D ABSCESS MULT OR COMP,1006100,CDM,521,RC,10061,HCPCS,Outpatient,,,577,403.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.5,50,,230.8,Percent of Total Billed Charges,50% of Total Billed Charges,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,177.57,486.85,
PARING CUTTING BEN LES 1,1105500,CDM,521,RC,11055,HCPCS,Outpatient,,,315,220.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.5,50,,126,Percent of Total Billed Charges,50% of Total Billed Charges,29.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,29.82,244.44,
PUNCH BIOPSY SKIN SINGLE LESIO,1110000,CDM,521,RC,11104,HCPCS,Outpatient,,,333,233.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.5,50,,133.2,Percent of Total Billed Charges,50% of Total Billed Charges,88.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.04,486.85,
PROC/EXC BENIGN LESION .5CM OR,1140000,CDM,521,RC,11400,HCPCS,Outpatient,,,153,107.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.5,50,,61.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,859.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,636.33,100,,,Fee Schedule,100% of CMS OPPS Rate,76.5,859.04,
"TRIMMING OF DYSTROPHIC NAILS,",1172200,CDM,521,RC,G0127,HCPCS,Outpatient,,,113,79.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.5,50,,45.2,Percent of Total Billed Charges,50% of Total Billed Charges,14.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,177.57,
PROC/EXC OF NAIL(INGROWN PERMA,1175000,CDM,521,RC,11750,HCPCS,Outpatient,,,353,247.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.5,50,,141.2,Percent of Total Billed Charges,50% of Total Billed Charges,190.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,486.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.63,100,,,Fee Schedule,100% of CMS OPPS Rate,176.5,486.85,
PROC/SIMPLE LACERATION REPAIR,1200100,CDM,521,RC,12001,HCPCS,Outpatient,,,180,126,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90,50,,72,Percent of Total Billed Charges,50% of Total Billed Charges,85.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,85.74,244.44,
DESTR BEN PREMAL 1 LESION,1700000,CDM,521,RC,17000,HCPCS,Outpatient,,,179,125.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.5,50,,71.6,Percent of Total Billed Charges,50% of Total Billed Charges,101.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,89.5,244.44,
DESTR BEN PREMAL 2 14 LESION,1700300,CDM,521,RC,17003,HCPCS,Outpatient,,,20,14,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,3.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.8,177.57,
DESTR BEN 1 14 LESN NOT SKN TG,1711000,CDM,521,RC,17110,HCPCS,Outpatient,,,307,214.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.5,50,,122.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,125.48,244.44,
INJECTION OF SINUS TRACT,2050000,CDM,521,RC,20500,HCPCS,Outpatient,,,604,422.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302,50,,241.6,Percent of Total Billed Charges,50% of Total Billed Charges,166.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1862.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1379.29,100,,,Fee Schedule,100% of CMS OPPS Rate,166.98,1862.03,
SCREENING TEST PURE TONE AIR O,9255100,CDM,521,RC,92551,HCPCS,Outpatient,,,37,25.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,21.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,177.57,
IMMUNO WO EXTRAC 1,9511500,CDM,521,RC,95115,HCPCS,Outpatient,,,26,18.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,13,177.57,
INJ/ALLERGY INJ. 2 OR MORE,9511700,CDM,521,RC,95117,HCPCS,Outpatient,,,44,30.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,50,,17.6,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,177.57,
INJECT THER DX SUBCU OR IM,9637200,CDM,521,RC,96372,HCPCS,Outpatient,,,43,30.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,50,,17.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,21.5,177.57,
POSTOPERATIVE FOLLOW-UP VISIT,9902400,CDM,521,RC,99024,HCPCS,Outpatient,,,,,,177.57,100,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,177.57,
OFF VISIT/NEW PT BRIEF,9920100,CDM,521,RC,99201,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFF VISIT/NEW DR STEELY BRIEF,9920145,CDM,521,RC,99201,HCPCS,Outpatient,,,152,106.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76,50,,60.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76,177.57,
OFF VISIT/NEW PT DR LANDRY BRI,9920147,CDM,521,RC,99201,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFF VISIT/NEW PT DR OLADIRAN B,9920152,CDM,521,RC,99201,HCPCS,Outpatient,,,126,88.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63,177.57,
OFF VISIT/NEW PT PAIN MGT BRIE,9920160,CDM,521,RC,99201,HCPCS,Outpatient,,,92,64.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,50,,36.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46,177.57,
OFF VISIT/NEW PT DR UNDA BRIEF,9920165,CDM,521,RC,99201,HCPCS,Outpatient,,,229,160.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.5,50,,91.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.5,177.57,
OFF VISIT/NEW PT UROLOGY,9920175,CDM,521,RC,99201,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920200,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFF VISIT/NEW DR LU,9920223,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFF VISIT/NEW DR PU,9920230,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920244,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920245,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920247,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920252,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920260,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920265,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFFICE OP NEW PT VISIT STRAIGH,9920275,CDM,521,RC,99202,HCPCS,Outpatient,,,135,94.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,50,,54,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,177.57,
OFF VISIT NEW/DR BAIN,9920280,CDM,521,RC,99202,HCPCS,Outpatient,,,149,104.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,50,,59.6,Percent of Total Billed Charges,50% of Total Billed Charges,89.96,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.5,177.57,
OFFICE OP NEW PT VISIT LOW,9920300,CDM,521,RC,99203,HCPCS,Outpatient,,,208,145.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,177.57,
OFF VISIT/NEW DR LU LOW COMPLE,9920323,CDM,521,RC,99203,HCPCS,Outpatient,,,208,145.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,177.57,
OFF VISIT/NEW DR PU LOW COMPLE,9920330,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT LOW,9920344,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT LOW,9920345,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT LOW,9920347,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT LOW,9920352,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT LOW,9920360,CDM,521,RC,99203,HCPCS,Outpatient,,,208,145.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,177.57,
OFFICE OP NEW PT VISIT LOW,9920365,CDM,521,RC,99203,HCPCS,Outpatient,,,208,145.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,177.57,
OFFICE OP NEW PT VISIT LOW,9920375,CDM,521,RC,99203,HCPCS,Outpatient,,,208,145.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,50,,83.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,177.57,
OFF VISIT NEW/DR BAIN,9920380,CDM,521,RC,99203,HCPCS,Outpatient,,,258,180.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,50,,103.2,Percent of Total Billed Charges,50% of Total Billed Charges,155.78,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129,177.57,
OFFICE OP NEW PT VISIT MOD,9920400,CDM,521,RC,99204,HCPCS,Outpatient,,,313,219.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,253.26,
OFF VISIT/NEW DR LU MOD COMPLE,9920423,CDM,521,RC,99204,HCPCS,Outpatient,,,313,219.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,253.26,
OFFICE OP NEW PT VISIT MOD,9920444,CDM,521,RC,99204,HCPCS,Outpatient,,,420,294,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,253.26,
OFFICE OP NEW PT VISIT MOD,9920445,CDM,521,RC,99204,HCPCS,Outpatient,,,420,294,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,253.26,
OFFICE OP NEW PT VISIT MOD,9920447,CDM,521,RC,99204,HCPCS,Outpatient,,,420,294,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,253.26,
OFFICE OP NEW PT VISIT MOD,9920452,CDM,521,RC,99204,HCPCS,Outpatient,,,420,294,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,253.26,
OFFICE OP NEW PT VISIT MOD,9920460,CDM,521,RC,99204,HCPCS,Outpatient,,,313,219.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,253.26,
OFFICE OP NEW PT VISIT MOD,9920465,CDM,521,RC,99204,HCPCS,Outpatient,,,313,219.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,253.26,
OFFICE OP NEW PT VISIT MOD,9920475,CDM,521,RC,99204,HCPCS,Outpatient,,,313,219.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,50,,125.2,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,253.26,
OFF VISIT NEW/DR BAIN,9920480,CDM,521,RC,99204,HCPCS,Outpatient,,,420,294,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210,50,,168,Percent of Total Billed Charges,50% of Total Billed Charges,253.26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,253.26,
OFFICE OP NEW PT VISIT HIGH,9920500,CDM,521,RC,99205,HCPCS,Outpatient,,,413,289.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFF VISIT/NEW DR LU HIGH COMPL,9920523,CDM,521,RC,99205,HCPCS,Outpatient,,,413,289.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920544,CDM,521,RC,99205,HCPCS,Outpatient,,,571,399.7,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920545,CDM,521,RC,99205,HCPCS,Outpatient,,,571,399.7,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920547,CDM,521,RC,99205,HCPCS,Outpatient,,,571,399.7,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920552,CDM,521,RC,99205,HCPCS,Outpatient,,,571,399.7,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920560,CDM,521,RC,99205,HCPCS,Outpatient,,,413,289.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920565,CDM,521,RC,99205,HCPCS,Outpatient,,,413,289.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFFICE OP NEW PT VISIT HIGH,9920575,CDM,521,RC,99205,HCPCS,Outpatient,,,413,289.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.5,50,,165.2,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFF VISIT NEW/DR BAIN,9920580,CDM,521,RC,99205,HCPCS,Outpatient,,,571,399.7,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.5,50,,228.4,Percent of Total Billed Charges,50% of Total Billed Charges,344.18,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,344.18,
OFF OP ESTAB MAY X REQ PHY/QHP,9921100,CDM,521,RC,99211,HCPCS,Outpatient,,,103,72.1,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,50,,41.2,Percent of Total Billed Charges,50% of Total Billed Charges,16.62,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.62,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921200,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFF VISIT/EST DR LU,9921223,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFF VISIT/EST DR PU,9921230,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921244,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921245,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921247,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921252,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921260,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921265,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921266,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFFICE OP ESTAB VISIT STRAIGHT,9921275,CDM,521,RC,99212,HCPCS,Outpatient,,,105,73.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,50,,42,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.5,177.57,
OFF VISIT EST/DR BAIN,9921280,CDM,521,RC,99212,HCPCS,Outpatient,,,112,78.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,50,,44.8,Percent of Total Billed Charges,50% of Total Billed Charges,67.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,177.57,
OFFICE OP ESTAB VISIT LOW,9921300,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFF VISIT/EST DR LU LOW COMPLE,9921323,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFF VISIT/EST DR PU LOW COMPLE,9921330,CDM,521,RC,99213,HCPCS,Outpatient,,,207,144.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,177.57,
OFFICE OP ESTAB VISIT LOW,9921344,CDM,521,RC,99213,HCPCS,Outpatient,,,207,144.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,177.57,
OFFICE OP ESTAB VISIT LOW,9921345,CDM,521,RC,99213,HCPCS,Outpatient,,,207,144.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,177.57,
OFFICE OP ESTAB VISIT LOW,9921352,CDM,521,RC,99213,HCPCS,Outpatient,,,207,144.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,177.57,
OFFICE OP ESTAB VISIT LOW,9921360,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFFICE OP ESTAB VISIT LOW,9921365,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFFICE OP ESTAB VISIT LOW,9921366,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFFICE OP ESTAB VISIT LOW,9921375,CDM,521,RC,99213,HCPCS,Outpatient,,,170,119,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,50,,68,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,177.57,
OFF VISIT EST/DR BAIN,9921380,CDM,521,RC,99213,HCPCS,Outpatient,,,207,144.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,50,,82.8,Percent of Total Billed Charges,50% of Total Billed Charges,125.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.5,177.57,
OFFICE OP ESTAB VISIT MOD,9921400,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFF VISIT/EST DR LU MOD COMPLE,9921423,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFF VISIT/EST DR BINDRA MOD CO,9921444,CDM,521,RC,99214,HCPCS,Outpatient,,,306,214.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,184.36,
OFFICE OP ESTAB VISIT MOD,9921445,CDM,521,RC,99214,HCPCS,Outpatient,,,306,214.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,184.36,
OFFICE OP ESTAB VISIT MOD,9921447,CDM,521,RC,99214,HCPCS,Outpatient,,,306,214.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,184.36,
OFFICE OP ESTAB VISIT MOD,9921452,CDM,521,RC,99214,HCPCS,Outpatient,,,306,214.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,184.36,
OFFICE OP ESTAB VISIT MOD,9921460,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFFICE OP ESTAB VISIT MOD,9921465,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFFICE OP ESTAB VISIT MOD,9921466,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFFICE OP ESTAB VISIT MOD,9921475,CDM,521,RC,99214,HCPCS,Outpatient,,,240,168,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,50,,96,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,184.36,
OFF VISIT EST/DR BAIN,9921480,CDM,521,RC,99214,HCPCS,Outpatient,,,306,214.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,50,,122.4,Percent of Total Billed Charges,50% of Total Billed Charges,184.36,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153,184.36,
OFFICE OP ESTAB VISIT HIGH,9921500,CDM,521,RC,99215,HCPCS,Outpatient,,,338,236.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,273.3,
OFF VISIT/EST DR LU HIGH COMPL,9921523,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
OFFICE OP ESTAB VISIT HIGH,9921544,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
OFFICE OP ESTAB VISIT HIGH,9921545,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
OFFICE OP ESTAB VISIT HIGH,9921547,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
OFFICE OP ESTAB VISIT HIGH,9921552,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
OFFICE OP ESTAB VISIT HIGH,9921560,CDM,521,RC,99215,HCPCS,Outpatient,,,338,236.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,273.3,
OFFICE OP ESTAB VISIT HIGH,9921565,CDM,521,RC,99215,HCPCS,Outpatient,,,338,236.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,273.3,
OFFICE OP ESTAB VISIT HIGH,9921566,CDM,521,RC,99215,HCPCS,Outpatient,,,338,236.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,273.3,
OFFICE OP ESTAB VISIT HIGH,9921575,CDM,521,RC,99215,HCPCS,Outpatient,,,338,236.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,50,,135.2,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169,273.3,
OFFICE OP ESTAB VISIT HIGH,9921580,CDM,521,RC,99215,HCPCS,Outpatient,,,454,317.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,227,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,273.3,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.57,273.3,
PREV/NEW OFF VISIT 0-1,9938100,CDM,521,RC,99381,HCPCS,Outpatient,,,157,109.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,50,,62.8,Percent of Total Billed Charges,50% of Total Billed Charges,138.86,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.5,177.57,
NEW PT PREVENT MED 1 TO 4,9938200,CDM,521,RC,99382,HCPCS,Outpatient,,,228,159.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,148.46,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,177.57,
NEW PT PREVENT MED 5 TO 11,9938300,CDM,521,RC,99383,HCPCS,Outpatient,,,237,165.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.5,50,,94.8,Percent of Total Billed Charges,50% of Total Billed Charges,157.4,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.5,177.57,
NEW PT PREVENT MED 12 TO 17,9938400,CDM,521,RC,99384,HCPCS,Outpatient,,,267,186.9,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,185.52,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.5,185.52,
NEW PT PREVENT MED 18 TO 39,9938500,CDM,521,RC,99385,HCPCS,Outpatient,,,259,181.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.5,50,,103.6,Percent of Total Billed Charges,50% of Total Billed Charges,177.92,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.5,177.92,
NEW PT PREVENT MED 40 TO 64,9938600,CDM,521,RC,99386,HCPCS,Outpatient,,,299,209.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.5,50,,119.6,Percent of Total Billed Charges,50% of Total Billed Charges,215.66,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.5,215.66,
NEW PT PREVENT MED 65PLUS,9938700,CDM,521,RC,99387,HCPCS,Outpatient,,,325,227.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.5,50,,130,Percent of Total Billed Charges,50% of Total Billed Charges,231.62,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162.5,231.62,
MEDICARE INITIAL ANNUAL WELLNE,9938800,CDM,521,RC,,,Outpatient,,,536,375.2,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,268,50,,214.4,Percent of Total Billed Charges,50% of Total Billed Charges,348.4,65,,278.72,Percent of Total Billed Charges,65% of Total Billed Charges,402,75,,321.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.2,20,,85.76,Percent of Total Billed Charges,20% of Total Billed Charges,321.6,60,,257.28,Percent of Total Billed Charges,60% of Total Billed Charges,109.34,20.4,,87.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,109.34,20.4,,87.47,Percent of Total Billed Charges,20.4% of Total Billed Charges,107.2,20,,85.76,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.2,402,
PREV/EST OFF VISIT 0-1,9939100,CDM,521,RC,99391,HCPCS,Outpatient,,,130,91,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65,50,,52,Percent of Total Billed Charges,50% of Total Billed Charges,126.7,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65,177.57,
EST PT PREVENT MED 1 TO 4,9939200,CDM,521,RC,99392,HCPCS,Outpatient,,,210,147,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,138.86,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,177.57,
EST PT PREVENT MED 5 T0 11,9939300,CDM,521,RC,99393,HCPCS,Outpatient,,,210,147,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,50,,84,Percent of Total Billed Charges,50% of Total Billed Charges,138.86,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105,177.57,
EST PT PREVENT MED 12 TO 17,9939400,CDM,521,RC,99394,HCPCS,Outpatient,,,228,159.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,50,,91.2,Percent of Total Billed Charges,50% of Total Billed Charges,157.4,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,177.57,
EST PT PREVENT MED 18 TO 39,9939500,CDM,521,RC,99395,HCPCS,Outpatient,,,234,163.8,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,50,,93.6,Percent of Total Billed Charges,50% of Total Billed Charges,162.52,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117,177.57,
EST PT PREVENT MED 40 TO 64,9939600,CDM,521,RC,99396,HCPCS,Outpatient,,,248,173.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,176.58,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124,177.57,
EST PT PREVENT MED 65PLUS,9939700,CDM,521,RC,99397,HCPCS,Outpatient,,,268,187.6,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,50,,107.2,Percent of Total Billed Charges,50% of Total Billed Charges,185.52,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,185.52,
MEDICARE SUBSEQUENT ANNUAL WEL,9939800,CDM,521,RC,,,Outpatient,,,419,293.3,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,209.5,50,,167.6,Percent of Total Billed Charges,50% of Total Billed Charges,272.35,65,,217.88,Percent of Total Billed Charges,65% of Total Billed Charges,314.25,75,,251.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.8,20,,67.04,Percent of Total Billed Charges,20% of Total Billed Charges,251.4,60,,201.12,Percent of Total Billed Charges,60% of Total Billed Charges,85.48,20.4,,68.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,85.48,20.4,,68.38,Percent of Total Billed Charges,20.4% of Total Billed Charges,83.8,20,,67.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.8,314.25,
CHRONIC CARE MANAGEMENT,9949000,CDM,521,RC,99490,HCPCS,Outpatient,,,202,141.4,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,95.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.61,100,,,Fee Schedule,100% of CMS OPPS Rate,80.61,177.57,
DOT PHYSICAL EXAMINATION,9949900,CDM,521,RC,99499,HCPCS,Outpatient,,,125,87.5,,177.57,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,177.57,
MRA ABDOMEN W/O CONTRAST,520608,CDM,610,RC,74185,HCPCS,Outpatient,,,1538,1076.6,A,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,22.5,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,4.8,Case Rate,Pays based on per visit rate,451.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.5,1050,
MRA ABDOMEN W&W/O CONTRAST,520609,CDM,610,RC,74185,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,10.94,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,14,Case Rate,Pays based on per visit rate,451.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.5,1602.76,
MRA ABDOMEN WITH CONTRAST,520610,CDM,610,RC,74185,HCPCS,Outpatient,,,1866,1306.2,C,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,2.43,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,14,Case Rate,Pays based on per visit rate,451.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.5,1268.88,
MRA CAROTID ART W/O CONTRAST,520618,CDM,610,RC,70547,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,52.8,Case Rate,Pays based on per visit rate,285.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA CAROTID ART W/CONTRAST,520619,CDM,610,RC,70548,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,3.6,Case Rate,Pays based on per visit rate,313.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1268.88,
MRI SPINAL CANAL CERV WO CON,520624,CDM,610,RC,72141,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,9.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,1520,Case Rate,Pays based on per visit rate,217.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI SPINAL CANAL WO W CON CERV,520625,CDM,610,RC,72156,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,9.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,26,Case Rate,Pays based on per visit rate,380.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI SPINAL CANAL CERV W CON,520626,CDM,610,RC,72142,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,9.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,6.8,Case Rate,Pays based on per visit rate,342.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI CHEST W/O CONTRAST,520627,CDM,610,RC,71550,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,9.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,479.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA CHEST W/O CONTRAST,520628,CDM,610,RC,71555,HCPCS,Outpatient,,,1538,1076.6,A,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,10.4,Case Rate,Pays based on per visit rate,445.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.8,1050,
MRI ABDOMEN ANGIOGRAPHY,520629,CDM,610,RC,74185,HCPCS,Outpatient,,,2563,1794.1,,126,100,,,fee schedule,100% Aetna Market fee schedule,1742.84,68,,1394.27,Percent of Total Billed Charges,68% of Total Billed Charges,1742.84,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,10.4,Case Rate,Pays based on per visit rate,451.5,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.5,1742.84,
MRI ABD WO CON,520630,CDM,610,RC,74181,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,8.8,Case Rate,Pays based on per visit rate,228.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI ANY JNT LOW XT WO CON,520631,CDM,610,RC,73721,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,32.22,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,248.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI CHEST W&W/O CONTRAST,520632,CDM,610,RC,71552,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,72.96,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,651.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
MRI CHEST WITH CONTRAST,520633,CDM,610,RC,71551,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,520.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,977.6,135,,,Fee Schedule,135% of CMS OPPS Rate,664.77,102,,,Fee Schedule,102% MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS rate,664.77,102,,,Fee Schedule,102% of MO Medicaid rate,651.74,100,,,Fee Schedule,100% of MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,520.62,1268.88,
MRI ABDOMEN W&W/O CONTRAST,520634,CDM,610,RC,74183,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,41.34,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,420.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
MRI ABDOMEN WITH CONTRAST,520635,CDM,610,RC,74182,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,43.78,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,395.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1268.88,
MRCP,520636,CDM,610,RC,74181,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,27.97,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,15.2,Case Rate,Pays based on per visit rate,228.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA CHEST WITH CONTRAST,520637,CDM,610,RC,71555,HCPCS,Outpatient,,,1866,1306.2,C,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,15.81,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,445.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.8,1268.88,
MRA CHEST W&W/O CONTRAST,520638,CDM,610,RC,71555,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,12.8,Case Rate,Pays based on per visit rate,445.8,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.8,1602.76,
MRI ANY JNT LOW XT WO W CON,520640,CDM,610,RC,73723,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,93.63,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,2,Case Rate,Pays based on per visit rate,508.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI ANY JNT LOW XT W CON,520641,CDM,610,RC,73722,HCPCS,Outpatient,,,3704,2592.8,,126,100,,,fee schedule,100% Aetna Market fee schedule,2518.72,68,,2014.98,Percent of Total Billed Charges,68% of Total Billed Charges,2518.72,68,,138.02,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,13.2,Case Rate,Pays based on per visit rate,423.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,977.6,135,,,Fee Schedule,135% of CMS OPPS Rate,664.77,102,,,Fee Schedule,102% MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS rate,664.77,102,,,Fee Schedule,102% of MO Medicaid rate,651.74,100,,,Fee Schedule,100% of MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.42,2518.72,
MRI SPINAL CANAL LUMB WO CON,520642,CDM,610,RC,72148,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,4.86,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,218.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI SPINAL CANAL LUMB WO W CON,520643,CDM,610,RC,72158,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,38.3,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,15.2,Case Rate,Pays based on per visit rate,379.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI SPINAL CANAL LUMB W CON,520644,CDM,610,RC,72149,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,28.8,Case Rate,Pays based on per visit rate,334.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI ORBIT FACE NECK WO CON,520645,CDM,610,RC,70540,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,2,Case Rate,Pays based on per visit rate,291.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI ORBIT FACE NECK W CON,520646,CDM,610,RC,70542,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,22.5,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,54.4,Case Rate,Pays based on per visit rate,343.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI ORBIT FACE NCK WO W CON,520648,CDM,610,RC,70543,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,15.2,Case Rate,Pays based on per visit rate,425.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI LOWER XTR WO W CON,520810,CDM,610,RC,73720,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,422.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI LOWER XTR WO CON,520811,CDM,610,RC,73718,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,286.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI LOWER XTR W CON,520812,CDM,610,RC,73719,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,33.2,Case Rate,Pays based on per visit rate,334.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI PELVIS WO W CON FS,520876,CDM,610,RC,72197,HCPCS,Outpatient,,,25,17.5,,126,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,17,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,32,Case Rate,Pays based on per visit rate,50,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17,1050,
MRI PELVIS WO CON,520877,CDM,610,RC,72195,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,15.2,Case Rate,Pays based on per visit rate,286.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI PELVIS W CON,520878,CDM,610,RC,72196,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,7.6,Case Rate,Pays based on per visit rate,335.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI ANY JNT UPP XT WO CON,520880,CDM,610,RC,73221,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,28.58,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,8.8,Case Rate,Pays based on per visit rate,248.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI ANY JNT UPP XT WO W CON FS,520885,CDM,610,RC,73223,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,20,Case Rate,Pays based on per visit rate,510.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI ANY JNT UPP XT W CON,520886,CDM,610,RC,73222,HCPCS,Outpatient,,,3704,2592.8,,126,100,,,fee schedule,100% Aetna Market fee schedule,2518.72,68,,2014.98,Percent of Total Billed Charges,68% of Total Billed Charges,2518.72,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,8.8,Case Rate,Pays based on per visit rate,422.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,977.6,135,,,Fee Schedule,135% of CMS OPPS Rate,664.77,102,,,Fee Schedule,102% MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS rate,664.77,102,,,Fee Schedule,102% of MO Medicaid rate,651.74,100,,,Fee Schedule,100% of MO Medicaid rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,651.74,100,,,Fee Schedule,100% of MO Medicaid Rate,724.15,100,,,Fee Schedule,100% of CMS OPPS Rate,422.26,2518.72,
MRI UPPER XTR WO W CON FS,520910,CDM,610,RC,73220,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,5.6,Case Rate,Pays based on per visit rate,550.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI UPPER XTR WO CON,520911,CDM,610,RC,73218,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,63.6,Case Rate,Pays based on per visit rate,426.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI UPPER XTR W CON,520912,CDM,610,RC,73219,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,28.58,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,10.8,Case Rate,Pays based on per visit rate,454.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRI SCROTUM AND CONTENTS,520915,CDM,610,RC,72195,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,42.56,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,13.2,Case Rate,Pays based on per visit rate,286.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI TMJ W/O CONTRAST,520920,CDM,610,RC,70336,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,85.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,8.4,Case Rate,Pays based on per visit rate,347.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI SPINAL CANAL THOR WO CON,520922,CDM,610,RC,72146,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,5.47,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,5.6,Case Rate,Pays based on per visit rate,216.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI SPINAL CANAL THOR WO W CON,520923,CDM,610,RC,72157,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,21.28,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,381.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI SPINAL CANAL THOR W CON,520924,CDM,610,RC,72147,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,46.21,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,33.2,Case Rate,Pays based on per visit rate,338.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRV BRAIN W/O CONTRAST,521000,CDM,610,RC,70544,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,38.3,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,15.2,Case Rate,Pays based on per visit rate,284.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRV BRAIN W&W/O CONTRAST,521005,CDM,610,RC,70546,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,51.07,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,128,Case Rate,Pays based on per visit rate,463.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
MRV BRAIN WITH CONTRAST,521010,CDM,610,RC,70545,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,46.21,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,11.2,Case Rate,Pays based on per visit rate,305.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,305.04,1268.88,
MRA CAROTID ART W&W/O CONTRAST,520620,CDM,610,RC,70549,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,,Case Rate,Pays based on per visit rate,465.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
3D RENDERING W/INTERP & POSTPR,893502,CDM,610,RC,76376,HCPCS,Outpatient,,,204,142.8,,11.33,100,,,fee schedule,100% Aetna Market fee schedule,138.72,68,,110.98,Percent of Total Billed Charges,68% of Total Billed Charges,138.72,68,,110.98,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,,Case Rate,Pays based on per visit rate,26.94,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.94,1050,
MRI BRAIN INC STEM WO CON,520603,CDM,611,RC,70551,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,822.62,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,30.4,Case Rate,Pays based on per visit rate,227.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRI BRAIN INC STEM WO W CON FS,520604,CDM,611,RC,70553,HCPCS,Outpatient,,,2516,1761.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1710.88,68,,1368.7,Percent of Total Billed Charges,68% of Total Billed Charges,1710.88,68,,822.62,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,30.4,Case Rate,Pays based on per visit rate,378.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1710.88,
MRI BRAIN INC STEM W CON,520605,CDM,611,RC,70552,HCPCS,Outpatient,,,1842,1289.4,,126,100,,,fee schedule,100% Aetna Market fee schedule,1252.56,68,,1002.05,Percent of Total Billed Charges,68% of Total Billed Charges,1252.56,68,,822.02,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,36,Case Rate,Pays based on per visit rate,334.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1252.56,
MRA HEAD W/O CONTRAST,520613,CDM,615,RC,70544,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,8.51,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,14,Case Rate,Pays based on per visit rate,284.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA HEAD W/CONTRAST,520614,CDM,615,RC,70545,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,10.8,Case Rate,Pays based on per visit rate,305.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,305.04,1268.88,
MRA NECK W/O CONTRAST,520621,CDM,615,RC,70547,HCPCS,Outpatient,,,1538,1076.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,1045.84,68,,836.67,Percent of Total Billed Charges,68% of Total Billed Charges,1045.84,68,,6.69,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,3.6,Case Rate,Pays based on per visit rate,285.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA NECK W/CONTRAST,520622,CDM,615,RC,70548,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,6.69,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,21.2,Case Rate,Pays based on per visit rate,313.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1268.88,
MRA NECK W&W/O CONTRAST,520623,CDM,615,RC,70549,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,9.73,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,181.2,Case Rate,Pays based on per visit rate,465.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
MRA HEAD WO CON,520615,CDM,618,RC,70544,HCPCS,Outpatient,,,1168,817.6,,126,100,,,fee schedule,100% Aetna Market fee schedule,794.24,68,,635.39,Percent of Total Billed Charges,68% of Total Billed Charges,794.24,68,,14.59,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,0.8,Case Rate,Pays based on per visit rate,284.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,1050,
MRA BRAIN WITH CONTRAST,520616,CDM,618,RC,70545,HCPCS,Outpatient,,,1866,1306.2,,126,100,,,fee schedule,100% Aetna Market fee schedule,1268.88,68,,1015.1,Percent of Total Billed Charges,68% of Total Billed Charges,1268.88,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,14,Case Rate,Pays based on per visit rate,305.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,305.04,1268.88,
MRA BRAIN W&W/O CONTRAST,520617,CDM,618,RC,70546,HCPCS,Outpatient,,,2357,1649.9,,126,100,,,fee schedule,100% Aetna Market fee schedule,1602.76,68,,1282.21,Percent of Total Billed Charges,68% of Total Billed Charges,1602.76,68,,6.08,Percent of Total Billed Charges,68% of Total Billed Charges,1050,100,,10.8,Case Rate,Pays based on per visit rate,463.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,469.55,135,,,Fee Schedule,135% of CMS OPPS Rate,319.3,102,,,Fee Schedule,102% MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS rate,319.3,102,,,Fee Schedule,102% of MO Medicaid rate,313.04,100,,,Fee Schedule,100% of MO Medicaid rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.04,100,,,Fee Schedule,100% of MO Medicaid Rate,347.82,100,,,Fee Schedule,100% of CMS OPPS Rate,313.04,1602.76,
ABSORPTIVE DRESSING > 16 SQ IN,17290,CDM,623,RC,A6252,HCPCS,Outpatient,,,3,2.1,,2.39,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,2.6,Other,Not Seperately Reimbusable,,,,3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.82,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
DRSG HYDROGEL TEGAG,18530,CDM,623,RC,Y7506,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,18.2,Other,Not Seperately Reimbusable,,,,21,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
TELFA 3X8,21600,CDM,623,RC,Y7509,HCPCS,Outpatient,,,3,2.1,,,,,,Other,Not Seperately Reimbusable,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ULCER DR-ULTEC 6X8,21910,CDM,623,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,24.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,1.04,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,0.96,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.33,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.32,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
LYOFOAM ADHESIVE,60975,CDM,623,RC,,,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,5.2,65,,4.16,Percent of Total Billed Charges,65% of Total Billed Charges,6,75,,4.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,4.8,60,,3.84,Percent of Total Billed Charges,60% of Total Billed Charges,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.63,20.4,,1.3,Percent of Total Billed Charges,20.4% of Total Billed Charges,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.6,20,,1.28,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.6,6.08,
ALTRAZEAL NANOFLEX HYDROGEL DR,60980,CDM,623,RC,Y7506,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,4.16,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,3.84,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.3,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.28,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
"TEGADERM 2 3/8"" X 2 3/4""",81037,CDM,623,RC,Y7507,HCPCS,Outpatient,,,8,5.6,,,,,,Other,Not Seperately Reimbusable,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,54.94,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,520,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
XEROFORM PETROLEUM DRESSING 4X,350240,CDM,623,RC,Y7509,HCPCS,Outpatient,,,6,4.2,,,,,,Other,Not Seperately Reimbusable,4.08,68,,3.26,Percent of Total Billed Charges,68% of Total Billed Charges,4.56,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,3,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3,4.56,
XEROFLO GAUZE DRESSING OVERWRA,350250,CDM,623,RC,Y7509,HCPCS,Outpatient,,,7,4.9,,,,,,Other,Not Seperately Reimbusable,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,229.57,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
"LOCM 200-299 MG/ML, IODINE, 1M",893000,CDM,636,RC,Q9966,HCPCS,Outpatient,,,350,245,,0.41,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,68,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,18.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175,266,
"LOCM 300-399MG/ML IODINE, 1ML",893499,CDM,636,RC,Q9967,HCPCS,Outpatient,,,405,283.5,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,275.4,68,,220.32,Percent of Total Billed Charges,68% of Total Billed Charges,307.8,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,202.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.5,307.8,
"LOCM 300-399MG/ML IODINE, 1ML,",893500,CDM,636,RC,Q9967,HCPCS,Outpatient,,,4,2.8,JW,0.13,100,,,fee schedule,100% Aetna Market fee schedule,2.72,68,,2.18,Percent of Total Billed Charges,68% of Total Billed Charges,3.04,76,,381.6,Percent of Total Billed Charges,76% of Total Billed Charges,2,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2,3.04,
D5W 1000ML IV,212950,CDM,636,RC,J7070,HCPCS,Outpatient,1000,ML,35,24.5,,4.25,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,411.26,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,32.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
D5NS 1000ML IV,213100,CDM,636,RC,J7042,HCPCS,Outpatient,1000,ML,35,24.5,,1.75,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,5.44,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
NORMAL SALINE 500ML IV,214200,CDM,636,RC,J7040,HCPCS,Outpatient,500,ML,35,24.5,,1.48,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,16.86,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,20.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
LEUPROLIDE INJ CAMCEVI 42MG,893667,CDM,636,RC,J1952,HCPCS,Outpatient,42,ME,3800,2660,,65.78,100,,,fee schedule,100% Aetna Market fee schedule,2584,68,,2067.2,Percent of Total Billed Charges,68% of Total Billed Charges,2888,76,,23.94,Percent of Total Billed Charges,76% of Total Billed Charges,1900,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55,100,,,Fee Schedule,100% of CMS OPPS Rate,55,2888,
NUC.MED. DOBUTAMINE 250MG,520365,CDM,636,RC,Y7506,HCPCS,Outpatient,250,ME,186,130.2,,,,,,Other,Not Seperately Reimbusable,126.48,68,,101.18,Percent of Total Billed Charges,68% of Total Billed Charges,141.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,93,50,,228.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93,141.36,
SUPPLY OF RDIA,520706,CDM,636,RC,A4641,HCPCS,Outpatient,,,161,112.7,,,,,,Other,Not Seperately Reimbusable,109.48,68,,87.58,Percent of Total Billed Charges,68% of Total Billed Charges,122.36,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,80.5,50,,140,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.5,122.36,
RDIA-GALLIUM 67,520950,CDM,636,RC,Y7506,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,41.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
RDIA-I131 CAPSULE,520951,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,72.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-I131 VIAL,520952,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,220.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TAGGED RBC-ULTRATAG,520953,CDM,636,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,34,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RDIA-TC99 HDP/OSTEOSCAN,520954,CDM,636,RC,Y7506,HCPCS,Outpatient,,,10,7,,,,,,Other,Not Seperately Reimbusable,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
RDIA-THALLUIM 201,520955,CDM,636,RC,Y7506,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,127.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
RDIA-CARDIOLITE,520956,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-CERETEC,520957,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-CHOLETEC,520958,CDM,636,RC,A9537,HCPCS,Outpatient,,,215,150.5,,53.77,100,,,fee schedule,100% Aetna Market fee schedule,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,40.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-IN111-DTPA,520959,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,52.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-IN111-ONCOSCINT,520960,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,195.78,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,61.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-WBCTAG,520961,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,74.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-ISOTOPE DMSA,520962,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,40.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-MAG-3,520963,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,56.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-SCHILLING'S CO57,520964,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,64,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-SESTAMIBI,520965,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,77.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 DTPA,520966,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,45.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 MAA,520967,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,59.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 MDP,520968,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,167.2,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,69.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 PERT,520969,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,90.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 SC,520970,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 MYOVIEW,520971,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,68.1,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,60.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-TC99 NEUROLITE,520972,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,72.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-I123,520973,CDM,636,RC,Y7506,HCPCS,Outpatient,,,95,66.5,,,,,,Other,Not Seperately Reimbusable,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,72.2,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,47.5,50,,76,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.5,72.2,
RDIA-ZENON,520974,CDM,636,RC,Y7506,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,146.2,68,,116.96,Percent of Total Billed Charges,68% of Total Billed Charges,163.4,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,107.5,50,,93.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.5,163.4,
RDIA-ACUTECT,520975,CDM,636,RC,Y7506,HCPCS,Outpatient,,,1069,748.3,,,,,,Other,Not Seperately Reimbusable,726.92,68,,581.54,Percent of Total Billed Charges,68% of Total Billed Charges,812.44,76,,72.35,Percent of Total Billed Charges,76% of Total Billed Charges,534.5,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,534.5,812.44,
KINEVAC 5MCG INJECTION,624685,CDM,636,RC,J2805,HCPCS,Outpatient,,,184,128.8,,146.41,100,,,fee schedule,100% Aetna Market fee schedule,125.12,68,,100.1,Percent of Total Billed Charges,68% of Total Billed Charges,139.84,76,,39.52,Percent of Total Billed Charges,76% of Total Billed Charges,92,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92,139.84,
LOCM 300-399 MG/ML IODINE PER,893542,CDM,636,RC,Q9967,HCPCS,Outpatient,,,1,0.7,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
ABILIFY 9.75MG INJ,600021,CDM,636,RC,J0400,HCPCS,Outpatient,975,ME,3,2.1,,0.36,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
ACETYLCYSTEINE 20% SOLUTION,600030,CDM,636,RC,J7608,HCPCS,Outpatient,,,55,38.5,,7.51,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,78.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
ACTIVASE 100MG INJ,600321,CDM,636,RC,J2997,HCPCS,Outpatient,100,ME,13699,9589.3,JG,97.87,100,,,fee schedule,100% Aetna Market fee schedule,9315.32,68,,7452.26,Percent of Total Billed Charges,68% of Total Billed Charges,10411.24,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,6849.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,10411.24,
ADENOCARD 6MG INJ,600337,CDM,636,RC,J0153,HCPCS,Outpatient,6,ME,218,152.6,,0.66,100,,,fee schedule,100% Aetna Market fee schedule,148.24,68,,118.59,Percent of Total Billed Charges,68% of Total Billed Charges,165.68,76,,209.15,Percent of Total Billed Charges,76% of Total Billed Charges,109,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109,165.68,
ADENOSCAN 90MG INJ,600338,CDM,636,RC,J0153,HCPCS,Outpatient,90,ME,1339,937.3,,0.66,100,,,fee schedule,100% Aetna Market fee schedule,910.52,68,,728.42,Percent of Total Billed Charges,68% of Total Billed Charges,1017.64,76,,980.1,Percent of Total Billed Charges,76% of Total Billed Charges,669.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,669.5,1017.64,
EPINEPHRINE 1:1000,600350,CDM,636,RC,J0171,HCPCS,Outpatient,,,14,9.8,,0.82,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,39.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
AGGRASTAT 250MCG/ML INJ,600650,CDM,636,RC,J3246,HCPCS,Outpatient,250,ML,2348,1643.6,,4.75,100,,,fee schedule,100% Aetna Market fee schedule,1596.64,68,,1277.31,Percent of Total Billed Charges,68% of Total Billed Charges,1784.48,76,,85.73,Percent of Total Billed Charges,76% of Total Billed Charges,1174,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.83,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.83,100,,,Fee Schedule,100% of CMS OPPS Rate,3.83,1784.48,
ALBUMIN 25% 50ML 12.5GM INJ,600750,CDM,636,RC,P9047,HCPCS,Outpatient,50,ML,256,179.2,,58.38,100,,,fee schedule,100% Aetna Market fee schedule,174.08,68,,139.26,Percent of Total Billed Charges,68% of Total Billed Charges,194.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,128,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,194.56,
ALBUTEROL SULFATE 5MG-INHALATI,600762,CDM,636,RC,J7611,HCPCS,Outpatient,5,ME,8,5.6,,0.16,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,0.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ALDOMET 250MG/5ML-INJ,601200,CDM,636,RC,J0210,HCPCS,Outpatient,250,ME,3,2.1,,38.88,100,,,fee schedule,100% Aetna Market fee schedule,2.04,68,,1.63,Percent of Total Billed Charges,68% of Total Billed Charges,2.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1.5,50,,84.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.5,2.28,
AMBISOME 50MG INJ,601525,CDM,636,RC,J0289,HCPCS,Outpatient,50,ME,1045,731.5,,29.32,100,,,fee schedule,100% Aetna Market fee schedule,710.6,68,,568.48,Percent of Total Billed Charges,68% of Total Billed Charges,794.2,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,522.5,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.33,794.2,
AMIKACIN 100MG INJ,601650,CDM,636,RC,J0278,HCPCS,Outpatient,100,ME,84,58.8,,0.91,100,,,fee schedule,100% Aetna Market fee schedule,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,2.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
AMIKACIN 250MG INJ,601700,CDM,636,RC,J0278,HCPCS,Outpatient,250,ME,214,149.8,,0.91,100,,,fee schedule,100% Aetna Market fee schedule,145.52,68,,116.42,Percent of Total Billed Charges,68% of Total Billed Charges,162.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,107,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107,162.64,
AMINOCAPROIC 5GM INJECTION,601832,CDM,636,RC,J0278,HCPCS,Outpatient,,,19,13.3,,0.91,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
AMINOPHYLLINE 500MG INJ,601850,CDM,636,RC,J0280,HCPCS,Outpatient,500,ME,14,9.8,YA,5.65,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
AMPHOTERICIN B 50MG IV SOL,602350,CDM,636,RC,J0285,HCPCS,Outpatient,50,ME,118,82.6,,10.49,100,,,fee schedule,100% Aetna Market fee schedule,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,1140.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59,89.68,
AMPICILLIN 250MG INJ,602750,CDM,636,RC,J0290,HCPCS,Outpatient,250,ME,14,9.8,YB,1.11,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
AMPICILLIN 500MG INJ,602800,CDM,636,RC,J0290,HCPCS,Outpatient,500,ME,27,18.9,,1.11,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
AMPICILLIN 1G INJ,602850,CDM,636,RC,J0290,HCPCS,Outpatient,,,33,23.1,,1.11,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
AMPICILLIN 2GM INJ,602851,CDM,636,RC,J0290,HCPCS,Outpatient,,,77,53.9,,1.11,100,,,fee schedule,100% Aetna Market fee schedule,52.36,68,,41.89,Percent of Total Billed Charges,68% of Total Billed Charges,58.52,76,,110.66,Percent of Total Billed Charges,76% of Total Billed Charges,38.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.5,58.52,
CEFAZOLIN 1GM INJ IVPB,603044,CDM,636,RC,J0690,HCPCS,Outpatient,,,35,24.5,,0.84,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
HYDRALAZINE HCL 20MG/CC-INJ,603700,CDM,636,RC,J0360,HCPCS,Outpatient,20,ME,90,63,,6.15,100,,,fee schedule,100% Aetna Market fee schedule,61.2,68,,48.96,Percent of Total Billed Charges,68% of Total Billed Charges,68.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,45,50,,87.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45,68.4,
VITAMIN K1 10MG/ML-INJ,603900,CDM,636,RC,J3430,HCPCS,Outpatient,110,ME,37,25.9,,3.19,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
AREDIA 30MG INJECTION,603958,CDM,636,RC,J2430,HCPCS,Outpatient,30,ME,1490,1043,,20.59,100,,,fee schedule,100% Aetna Market fee schedule,1013.2,68,,810.56,Percent of Total Billed Charges,68% of Total Billed Charges,1132.4,76,,76,Percent of Total Billed Charges,76% of Total Billed Charges,745,50,,27.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745,1132.4,
AREDIA 60 MG IV,603960,CDM,636,RC,J2430,HCPCS,Outpatient,60,ME,1334,933.8,,20.59,100,,,fee schedule,100% Aetna Market fee schedule,907.12,68,,725.7,Percent of Total Billed Charges,68% of Total Billed Charges,1013.84,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,667,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,667,1013.84,
HYDROXYZINE 25MG INJ,604800,CDM,636,RC,J3410,HCPCS,Outpatient,25,ME,8,5.6,,10.9,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HYDROXYZINE HCL 100MG/2ML INJ,604875,CDM,636,RC,J3410,HCPCS,Outpatient,100,ME,22,15.4,,10.9,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
ATIVAN 2MG INJ,604977,CDM,636,RC,J2060,HCPCS,Outpatient,2,ME,24,16.8,,1.23,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,37.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
ATROPINE 1MG/1ML INJ,605050,CDM,636,RC,J0461,HCPCS,Outpatient,11,ME,14,9.8,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
ATROPINE 1MG/1ML INJ,605100,CDM,636,RC,J0461,HCPCS,Outpatient,11,ME,35,24.5,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
ATROPINE 0.4MG/ML INJ,605200,CDM,636,RC,J0461,HCPCS,Outpatient,4,ME,42,29.4,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,28.56,68,,22.85,Percent of Total Billed Charges,68% of Total Billed Charges,31.92,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,21,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21,31.92,
AZACTAM 1GM-INJ,605534,CDM,636,RC,J3490,HCPCS,Outpatient,,,146,102.2,,,,,,Other,Not Seperately Reimbusable,99.28,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,110.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,73,50,,52.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73,110.96,
AZITHROMYCIN 500MG ADV,605537,CDM,636,RC,J0456,HCPCS,Outpatient,500,ME,70,49,,2.86,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
TICE BCG 80MG INJECTION,605975,CDM,636,RC,J9030,HCPCS,Outpatient,80,ME,939,657.3,,3.18,100,,,fee schedule,100% Aetna Market fee schedule,638.52,68,,510.82,Percent of Total Billed Charges,68% of Total Billed Charges,713.64,76,,46.82,Percent of Total Billed Charges,76% of Total Billed Charges,469.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,469.5,713.64,
DIPHENHYDRAMINE 50MG-INJ,606300,CDM,636,RC,J1200,HCPCS,Outpatient,50,ME,14,9.8,,0.88,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
"BICILLIN CR 600,000 UNITS INJ",606994,CDM,636,RC,J0561,HCPCS,Outpatient,,,136,95.2,,23.9,100,,,fee schedule,100% Aetna Market fee schedule,92.48,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,103.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,68,50,,98.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,103.36,
BICILLIN CR 900/300-INJ,607054,CDM,636,RC,J0558,HCPCS,Outpatient,,,173,121.1,,19.34,100,,,fee schedule,100% Aetna Market fee schedule,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.52,100,,,Fee Schedule,100% of CMS OPPS Rate,19.52,131.48,
BICILLIN LA 1.2MIL UNITS INJ,607150,CDM,636,RC,J0561,HCPCS,Outpatient,,,209,146.3,,23.9,100,,,fee schedule,100% Aetna Market fee schedule,142.12,68,,113.7,Percent of Total Billed Charges,68% of Total Billed Charges,158.84,76,,10.94,Percent of Total Billed Charges,76% of Total Billed Charges,104.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,158.84,
BOTOX 100 UNITS INJ,607375,CDM,636,RC,J0585,HCPCS,Outpatient,,,1448,1013.6,,6.96,100,,,fee schedule,100% Aetna Market fee schedule,984.64,68,,787.71,Percent of Total Billed Charges,68% of Total Billed Charges,1100.48,76,,273.6,Percent of Total Billed Charges,76% of Total Billed Charges,724,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,1100.48,
BRETHINE 1MG/1ML AMP-INJ,607500,CDM,636,RC,J3105,HCPCS,Outpatient,11,ME,173,121.1,,8.57,100,,,fee schedule,100% Aetna Market fee schedule,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.5,131.48,
BREVIBLOC 10MG-INJ,607579,CDM,636,RC,J3490,HCPCS,Outpatient,10,ME,138,96.6,,,,,,Other,Not Seperately Reimbusable,93.84,68,,75.07,Percent of Total Billed Charges,68% of Total Billed Charges,104.88,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,69,50,,62.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69,104.88,
BONIVA 3MG INJ,607800,CDM,636,RC,J1740,HCPCS,Outpatient,3,ME,1221,854.7,,28.16,100,,,fee schedule,100% Aetna Market fee schedule,830.28,68,,664.22,Percent of Total Billed Charges,68% of Total Billed Charges,927.96,76,,252.93,Percent of Total Billed Charges,76% of Total Billed Charges,610.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.5,927.96,
BUMEX 1MG/4ML INJ,607811,CDM,636,RC,J1939,HCPCS,Outpatient,14,ME,14,9.8,,0.73,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
BUMEX 2.5MG/10ML INJ,607815,CDM,636,RC,J1939,HCPCS,Outpatient,2510,ME,11,7.7,,0.73,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.5,8.36,
CALCIMAR 200I.U./ML -INJ,608280,CDM,636,RC,J0630,HCPCS,Outpatient,200,ML,150,105,,1176.45,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,454.78,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1583.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1173.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,75,1583.63,
CALCIUM DISODIUM VERSENATE 200,608289,CDM,636,RC,J0600,HCPCS,Outpatient,,,252,176.4,,6312.78,100,,,fee schedule,100% Aetna Market fee schedule,171.36,68,,137.09,Percent of Total Billed Charges,68% of Total Billed Charges,191.52,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,126,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8216.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6086.32,100,,,Fee Schedule,100% of CMS OPPS Rate,126,8216.53,
CALCIUM GLUCONATE 4.65MEQ-INJ,608295,CDM,636,RC,J0612,HCPCS,Outpatient,,,14,9.8,,0.06,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.04,100,,,Fee Schedule,100% of CMS OPPS Rate,0.04,10.64,
CALDOLOR 400MG INJ,608305,CDM,636,RC,,,Outpatient,400,ME,49,34.3,,,,,,Other,Not Seperately Reimbusable,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,31.85,65,,25.48,Percent of Total Billed Charges,65% of Total Billed Charges,36.75,75,,29.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,29.4,60,,23.52,Percent of Total Billed Charges,60% of Total Billed Charges,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,10,20.4,,8,Percent of Total Billed Charges,20.4% of Total Billed Charges,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.8,20,,7.84,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,9.8,37.24,
CARNITOR 1GM INJ,608500,CDM,636,RC,J1955,HCPCS,Outpatient,,,205,143.5,,38.85,100,,,fee schedule,100% Aetna Market fee schedule,139.4,68,,111.52,Percent of Total Billed Charges,68% of Total Billed Charges,155.8,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,102.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.5,155.8,
DILTIAZEM HCL 50MG/10ML INJ,608531,CDM,636,RC,J3490,HCPCS,Outpatient,5010,ME,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,62.02,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,78.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
DICLOFENAC 100GM GEL,608675,CDM,636,RC,J1130,HCPCS,Outpatient,,,150,105,,0.2,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
CATH FLO ACTIVASE 2MG INJ,608725,CDM,636,RC,J2997,HCPCS,Outpatient,2,ME,412,288.4,,97.87,100,,,fee schedule,100% Aetna Market fee schedule,280.16,68,,224.13,Percent of Total Billed Charges,68% of Total Billed Charges,313.12,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,206,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.47,313.12,
CEFAZOLIN 500MG PREMIX INJ,609150,CDM,636,RC,J0690,HCPCS,Outpatient,500,ME,21,14.7,,0.84,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
CEFEPIME 1GM PRE IV,609151,CDM,636,RC,J0692,HCPCS,Outpatient,,,85,59.5,,1.39,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,890,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
CEFEPIME 2GM PRE IV,609152,CDM,636,RC,J0692,HCPCS,Outpatient,,,121,84.7,,1.39,100,,,fee schedule,100% Aetna Market fee schedule,82.28,68,,65.82,Percent of Total Billed Charges,68% of Total Billed Charges,91.96,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,60.5,50,,64,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.5,91.96,
CELESTONE 6MG/CC INJ,609300,CDM,636,RC,J0702,HCPCS,Outpatient,6,ME,38,26.6,,7.5,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
CIPRO 200MG-INJ,610175,CDM,636,RC,J0744,HCPCS,Outpatient,200,ME,164,114.8,,2.13,100,,,fee schedule,100% Aetna Market fee schedule,111.52,68,,89.22,Percent of Total Billed Charges,68% of Total Billed Charges,124.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,82,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82,124.64,
CIPRO PREMIXED 400MG,610178,CDM,636,RC,J0744,HCPCS,Outpatient,400,ME,40,28,,2.13,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
CLAFORAN 1GM INJ,610225,CDM,636,RC,J0698,HCPCS,Outpatient,,,71,49.7,,9.53,100,,,fee schedule,100% Aetna Market fee schedule,48.28,68,,38.62,Percent of Total Billed Charges,68% of Total Billed Charges,53.96,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,35.5,50,,23.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.5,53.96,
CLAFORAN 1GM INJ,610226,CDM,636,RC,J0698,HCPCS,Outpatient,,,83,58.1,,9.53,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,35.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.5,63.08,
CLAFORAN 500MG INJ,610227,CDM,636,RC,J0698,HCPCS,Outpatient,500,ME,55,38.5,,9.53,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,27.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
CLAFORAN 2GM INJ,610228,CDM,636,RC,J0698,HCPCS,Outpatient,,,129,90.3,,9.53,100,,,fee schedule,100% Aetna Market fee schedule,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,98.04,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,64.5,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.5,98.04,
CLINDAMYCIN 300MG INJ,610232,CDM,636,RC,S0077,HCPCS,Outpatient,300,ME,33,23.1,,,,,,Other,Not Seperately Reimbusable,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
CLEOCIN 600MG-INJ,610233,CDM,636,RC,J3490,HCPCS,Outpatient,600,ME,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
CLEOCIN PHOSPHATE 900MG INJ,610237,CDM,636,RC,J3490,HCPCS,Outpatient,900,ME,82,57.4,,,,,,Other,Not Seperately Reimbusable,55.76,68,,44.61,Percent of Total Billed Charges,68% of Total Billed Charges,62.32,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,41,50,,7.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41,62.32,
CODEINE 30-60 INJ,610454,CDM,636,RC,J0745,HCPCS,Outpatient,,,8,5.6,,1.07,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
COGENTIN 2MG INJ,610501,CDM,636,RC,J0515,HCPCS,Outpatient,2,ME,303,212.1,,18.08,100,,,fee schedule,100% Aetna Market fee schedule,206.04,68,,164.83,Percent of Total Billed Charges,68% of Total Billed Charges,230.28,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,151.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.5,230.28,
PROCHLORPERAZINE 10MG/2ML INJE,610700,CDM,636,RC,J0780,HCPCS,Outpatient,102,ME,61,42.7,,3.77,100,,,fee schedule,100% Aetna Market fee schedule,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
AMIODARONE 150MG/3ML INJECTION,610900,CDM,636,RC,J0282,HCPCS,Outpatient,1503,ME,39,27.3,,0.49,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
CORTROSYN 0.25MG INJ,611378,CDM,636,RC,J0834,HCPCS,Outpatient,25,ME,97,67.9,,29.83,100,,,fee schedule,100% Aetna Market fee schedule,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,73.72,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,48.5,50,,22,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.5,73.72,
CUBICIN 500MG INJ,611500,CDM,636,RC,J0878,HCPCS,Outpatient,500,ME,1041,728.7,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,707.88,68,,566.3,Percent of Total Billed Charges,68% of Total Billed Charges,791.16,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,520.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,520.5,791.16,
CROFAB 2ML INJ,611570,CDM,636,RC,J0840,HCPCS,Outpatient,2,ML,2745,1921.5,,2144.91,100,,,fee schedule,100% Aetna Market fee schedule,1866.6,68,,1493.28,Percent of Total Billed Charges,68% of Total Billed Charges,2086.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1372.5,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2379.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1762.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1762.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1372.5,2379.17,
CYANOCOBALAMIN 1MG/CC INJ,611600,CDM,636,RC,J3420,HCPCS,Outpatient,1,ME,14,9.8,,1.59,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DALBAVANCIN 500MG INJ,611980,CDM,636,RC,C9443,HCPCS,Outpatient,500,ME,2951,2065.7,,,,,,Other,Not Seperately Reimbusable,2006.68,68,,1605.34,Percent of Total Billed Charges,68% of Total Billed Charges,2242.76,76,,70.53,Percent of Total Billed Charges,76% of Total Billed Charges,1475.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1475.5,2242.76,
DANTROLENE 20MG INJ,612095,CDM,636,RC,J3490,HCPCS,Outpatient,20,ME,330,231,,,,,,Other,Not Seperately Reimbusable,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,165,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,250.8,
DDAVP-INJ 4MCG/ML,612500,CDM,636,RC,J2597,HCPCS,Outpatient,4,ML,282,197.4,,6.96,100,,,fee schedule,100% Aetna Market fee schedule,191.76,68,,153.41,Percent of Total Billed Charges,68% of Total Billed Charges,214.32,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,141,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5.42,214.32,
DECADRON 10MG/ML,612552,CDM,636,RC,J1100,HCPCS,Outpatient,10,ME,10,7,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
DEXAMETHASONE 4MG/ML INJ,612600,CDM,636,RC,J1100,HCPCS,Outpatient,4,ME,1,0.7,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
DEXAMETHASONE 10MG INJ,612625,CDM,636,RC,J1100,HCPCS,Outpatient,10,ME,1,0.7,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,145.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
DEXAMETHASONE 0.5MG/5ML-INJ,612850,CDM,636,RC,J1100,HCPCS,Outpatient,55,ME,8,5.6,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
DELESTROGEN 20MG/ML -INJ,613250,CDM,636,RC,J1380,HCPCS,Outpatient,20,ME,38,26.6,,10.16,100,,,fee schedule,100% Aetna Market fee schedule,25.84,68,,20.67,Percent of Total Billed Charges,68% of Total Billed Charges,28.88,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,19,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19,28.88,
DEMADEX 20MG IV,613271,CDM,636,RC,J3265,HCPCS,Outpatient,20,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
DEMADEX 50MG INJECTION,613273,CDM,636,RC,J3265,HCPCS,Outpatient,50,ME,47,32.9,,,,,,Other,Not Seperately Reimbusable,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.5,35.72,
DEPO-MEDROL 80MG/ML -INJ,613500,CDM,636,RC,J1040,HCPCS,Outpatient,80,ME,81,56.7,,,,,,Other,Not Seperately Reimbusable,55.08,68,,44.06,Percent of Total Billed Charges,68% of Total Billed Charges,61.56,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,40.5,50,,13.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.5,61.56,
DEPO-PROVERA 150MG/CC-INJ,613550,CDM,636,RC,J1050,HCPCS,Outpatient,150,ME,314,219.8,,0.53,100,,,fee schedule,100% Aetna Market fee schedule,213.52,68,,170.82,Percent of Total Billed Charges,68% of Total Billed Charges,238.64,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,157,50,,13.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157,238.64,
DEXTRAN 40 10% 500ML,613700,CDM,636,RC,J7100,HCPCS,Outpatient,500,ML,192,134.4,,34.49,100,,,fee schedule,100% Aetna Market fee schedule,130.56,68,,104.45,Percent of Total Billed Charges,68% of Total Billed Charges,145.92,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,96,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96,145.92,
DIFLUCAN 100MG/50ML IV,614233,CDM,636,RC,,,Outpatient,100,ME,59,41.3,,,,,,Other,Not Seperately Reimbusable,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,231.04,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,111.2,Percent of Total Billed Charges,50% of Total Billed Charges,38.35,65,,30.68,Percent of Total Billed Charges,65% of Total Billed Charges,44.25,75,,35.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,35.4,60,,28.32,Percent of Total Billed Charges,60% of Total Billed Charges,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,12.04,20.4,,9.63,Percent of Total Billed Charges,20.4% of Total Billed Charges,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.8,20,,9.44,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.8,44.84,
FLUCONAZOLE 200MG/100ML IV,614236,CDM,636,RC,J1450,HCPCS,Outpatient,200,ME,481,336.7,,3.08,100,,,fee schedule,100% Aetna Market fee schedule,327.08,68,,261.66,Percent of Total Billed Charges,68% of Total Billed Charges,365.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,240.5,50,,30,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.5,365.56,
DIGIBIND-INJ,614257,CDM,636,RC,J1162,HCPCS,Outpatient,,,4130,2891,,5255.19,100,,,fee schedule,100% Aetna Market fee schedule,2808.4,68,,2246.72,Percent of Total Billed Charges,68% of Total Billed Charges,3138.8,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,2065,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6598.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4888.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4888.1,100,,,Fee Schedule,100% of CMS OPPS Rate,2065,6598.93,
PHENYTOIN 100MG/2ML INJ,614447,CDM,636,RC,J1165,HCPCS,Outpatient,100,ME,14,9.8,,0.69,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DILANTIN 100 MG AMP-INJ,614458,CDM,636,RC,J1165,HCPCS,Outpatient,100,ME,35,24.5,,0.69,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
DIHYDROERGOTAMINE 1MG INJ,614510,CDM,636,RC,J1110,HCPCS,Outpatient,1,ME,170,119,,46.58,100,,,fee schedule,100% Aetna Market fee schedule,115.6,68,,92.48,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,76,,91.2,Percent of Total Billed Charges,76% of Total Billed Charges,85,50,,52.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85,129.2,
DILAUDID 4MG INJ,614525,CDM,636,RC,J1170,HCPCS,Outpatient,4,ME,14,9.8,,5.05,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,93.63,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,57.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DIMENHYDRINATE 50MG-INJ,614950,CDM,636,RC,J1240,HCPCS,Outpatient,50,ME,44,30.8,,9.85,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,1528,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
PROPOFOL 200MG/20ML INJ,614968,CDM,636,RC,J2704,HCPCS,Outpatient,200,ME,33,23.1,,0.14,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
DIURIL .5G INJ,615004,CDM,636,RC,J1205,HCPCS,Outpatient,,,68,47.6,,133.48,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
DOBUTAMINE 1000MG PREMIX INJ,615201,CDM,636,RC,J1250,HCPCS,Outpatient,1000,ME,324,226.8,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,220.32,68,,176.26,Percent of Total Billed Charges,68% of Total Billed Charges,246.24,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,162,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,162,246.24,
DOBUTAMINE 250MG PREMIX INJ,615205,CDM,636,RC,J1250,HCPCS,Outpatient,250,ME,136,95.2,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,92.48,68,,73.98,Percent of Total Billed Charges,68% of Total Billed Charges,103.36,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,68,50,,20189.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68,103.36,
DOBUTREX 250MG-INJ,615207,CDM,636,RC,J1250,HCPCS,Outpatient,250,ME,59,41.3,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,40.12,68,,32.1,Percent of Total Billed Charges,68% of Total Billed Charges,44.84,76,,220.7,Percent of Total Billed Charges,76% of Total Billed Charges,29.5,50,,63.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.5,44.84,
DOPAMINE PREMIX 250CC-INJ,615560,CDM,636,RC,J1265,HCPCS,Outpatient,,,87,60.9,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,59.16,68,,47.33,Percent of Total Billed Charges,68% of Total Billed Charges,66.12,76,,75.39,Percent of Total Billed Charges,76% of Total Billed Charges,43.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.5,66.12,
DOPAMINE 400MG/10ML INJ,615568,CDM,636,RC,J1265,HCPCS,Outpatient,,,24,16.8,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,12,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
DOPAMINE 800MCG/250 ML INJ,615570,CDM,636,RC,J1265,HCPCS,Outpatient,250,ML,53,37.1,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.5,40.28,
DURAMORPH 10MG INJECTION,616070,CDM,636,RC,J2274,HCPCS,Outpatient,10,ME,20,14,,12.37,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
ELIGARD 45 MG INJ,616908,CDM,636,RC,J9217,HCPCS,Outpatient,45,ME,4878,3414.6,,199.43,100,,,fee schedule,100% Aetna Market fee schedule,3317.04,68,,2653.63,Percent of Total Billed Charges,68% of Total Billed Charges,3707.28,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,2439,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,176.51,3707.28,
EPINEPHRINE ABBOJECT 1:10000 2,617300,CDM,636,RC,J0171,HCPCS,Outpatient,,,33,23.1,,0.82,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,169.02,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,169.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
EPOGEN 2000 U -INJ,617305,CDM,636,RC,J0885,HCPCS,Outpatient,,,150,105,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,114,
EPOGEN 20000 U INJ/1000,617308,CDM,636,RC,J0885,HCPCS,Outpatient,,,1606,1124.2,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,1092.08,68,,873.66,Percent of Total Billed Charges,68% of Total Billed Charges,1220.56,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,803,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,1220.56,
EPOGEN 3000 U-INJ/1000,617309,CDM,636,RC,J0885,HCPCS,Outpatient,,,225,157.5,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,153,68,,122.4,Percent of Total Billed Charges,68% of Total Billed Charges,171,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,112.5,50,,234.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,171,
EPOETIN ALFA 40K UNITS,617312,CDM,636,RC,J0885,HCPCS,Outpatient,,,2469,1728.3,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,1678.92,68,,1343.14,Percent of Total Billed Charges,68% of Total Billed Charges,1876.44,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,1234.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,1876.44,
EPOGEN 10000 U NON-DIALYSIS,617315,CDM,636,RC,J0885,HCPCS,Outpatient,,,1235,864.5,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,839.8,68,,671.84,Percent of Total Billed Charges,68% of Total Billed Charges,938.6,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,617.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,938.6,
ERYTHROMYCIN 1GM ADV INJ,617497,CDM,636,RC,J1364,HCPCS,Outpatient,,,31,21.7,,88.85,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,435.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,88.26,
ERYTHROMYCIN 500MG ADV INJ,617660,CDM,636,RC,J1364,HCPCS,Outpatient,500,ME,49,34.3,,88.85,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,87.55,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.38,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,88.26,
EXPAREL 133MG INJ,617850,CDM,636,RC,J3490,HCPCS,Outpatient,133,ME,816,571.2,,,,,,Other,Not Seperately Reimbusable,554.88,68,,443.9,Percent of Total Billed Charges,68% of Total Billed Charges,620.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,408,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408,620.16,
ESMOLOL 2000MG/100ML IVPB,617869,CDM,636,RC,J3490,HCPCS,Outpatient,,,689,482.3,,,,,,Other,Not Seperately Reimbusable,468.52,68,,374.82,Percent of Total Billed Charges,68% of Total Billed Charges,523.64,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,344.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.5,523.64,
ETHAMOLIN 5% INJ,617880,CDM,636,RC,Y7506,HCPCS,Outpatient,,,346,242.2,,,,,,Other,Not Seperately Reimbusable,235.28,68,,188.22,Percent of Total Billed Charges,68% of Total Billed Charges,262.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,173,50,,13.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173,262.96,
ETHANOL 10ML INJ,617895,CDM,636,RC,,,Outpatient,10,ML,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,97.28,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.25,75,,33,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,33,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11,41.8,
ETOMIDATE 40MG INJ,617920,CDM,636,RC,J3490,HCPCS,Outpatient,40,ME,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
FERRLECIT 62.5MG INJ,618100,CDM,636,RC,J2916,HCPCS,Outpatient,625,ME,229,160.3,,2.61,100,,,fee schedule,100% Aetna Market fee schedule,155.72,68,,124.58,Percent of Total Billed Charges,68% of Total Billed Charges,174.04,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,114.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.5,174.04,
FLUPHENAZINE DEC 125MG INJ,618580,CDM,636,RC,J2680,HCPCS,Outpatient,125,ME,305,213.5,,10.07,100,,,fee schedule,100% Aetna Market fee schedule,207.4,68,,165.92,Percent of Total Billed Charges,68% of Total Billed Charges,231.8,76,,179.97,Percent of Total Billed Charges,76% of Total Billed Charges,152.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.5,231.8,
FORTAZ 500MG IV,618678,CDM,636,RC,J0713,HCPCS,Outpatient,500,ME,43,30.1,,1.86,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,246.85,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
FORTAZ 1GM-INJ,618680,CDM,636,RC,J0713,HCPCS,Outpatient,,,88,61.6,,1.86,100,,,fee schedule,100% Aetna Market fee schedule,59.84,68,,47.87,Percent of Total Billed Charges,68% of Total Billed Charges,66.88,76,,330.75,Percent of Total Billed Charges,76% of Total Billed Charges,44,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44,66.88,
FORTAZ 2GM INJ - A/V,618683,CDM,636,RC,J0713,HCPCS,Outpatient,,,154,107.8,,1.86,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
FUNGIZONE 50MG INJ,618700,CDM,636,RC,J0285,HCPCS,Outpatient,50,ME,112,78.4,,10.49,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,4451.17,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
FUROSEMIDE 100MG INJECTION,618725,CDM,636,RC,J1940,HCPCS,Outpatient,100,ME,20,14,,0.63,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
GAMMAGUARD 30GM 300ML,618950,CDM,636,RC,J1569,HCPCS,Outpatient,30300,ML,6235,4364.5,,48.57,100,,,fee schedule,100% Aetna Market fee schedule,4239.8,68,,3391.84,Percent of Total Billed Charges,68% of Total Billed Charges,4738.6,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,3117.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,4738.6,
GENTAMICIN SULFATE 20MG/2CC IN,619250,CDM,636,RC,J1580,HCPCS,Outpatient,202,ME,14,9.8,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
GENTAMICIN 80MG/100ML IVPB,619270,CDM,636,RC,J1580,HCPCS,Outpatient,,,37,25.9,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,356.29,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
GENTAMICIN 80MG-INJ,619350,CDM,636,RC,J1580,HCPCS,Outpatient,80,ME,19,13.3,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
GEODON 20MG INJ,619370,CDM,636,RC,J3486,HCPCS,Outpatient,20,ME,238,166.6,,10.73,100,,,fee schedule,100% Aetna Market fee schedule,161.84,68,,129.47,Percent of Total Billed Charges,68% of Total Billed Charges,180.88,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,119,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,180.88,
GENTAMYCIN 100MG PREMIX INJ,619400,CDM,636,RC,J1580,HCPCS,Outpatient,100,ME,47,32.9,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,1659.23,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.5,35.72,
GRANIX 480 MCG INJ,619975,CDM,636,RC,J1447,HCPCS,Outpatient,,,573,401.1,,0.48,100,,,fee schedule,100% Aetna Market fee schedule,389.64,68,,311.71,Percent of Total Billed Charges,68% of Total Billed Charges,435.48,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,286.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.39,435.48,
GLUCAGEN 1MG INJ,619999,CDM,636,RC,J1610,HCPCS,Outpatient,1,ME,410,287,,207.2,100,,,fee schedule,100% Aetna Market fee schedule,278.8,68,,223.04,Percent of Total Billed Charges,68% of Total Billed Charges,311.6,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,205,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,192.3,311.6,
GLUCAGON 1MG VIAL -INJ,620000,CDM,636,RC,J1610,HCPCS,Outpatient,1,ME,416,291.2,,207.2,100,,,fee schedule,100% Aetna Market fee schedule,282.88,68,,226.3,Percent of Total Billed Charges,68% of Total Billed Charges,316.16,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,208,50,,58,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.3,100,,,Fee Schedule,100% of CMS OPPS Rate,192.3,316.16,
GLYCOPYRROLATE 0.2MG/ML INJ,620026,CDM,636,RC,J3490,HCPCS,Outpatient,2,ME,70,49,,,,,,Other,Not Seperately Reimbusable,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,10,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
HALDOL 5MG/ML AMP-INJ,620400,CDM,636,RC,J1630,HCPCS,Outpatient,5,ME,48,33.6,,1.56,100,,,fee schedule,100% Aetna Market fee schedule,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,659.07,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
HALDOL DECONOATE 50MG INJ,620405,CDM,636,RC,J1631,HCPCS,Outpatient,50,ME,259,181.3,,9.65,100,,,fee schedule,100% Aetna Market fee schedule,176.12,68,,140.9,Percent of Total Billed Charges,68% of Total Billed Charges,196.84,76,,148.96,Percent of Total Billed Charges,76% of Total Billed Charges,129.5,50,,27.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.5,196.84,
HEPARIN 10 U FLUSH INJ,620750,CDM,636,RC,J1642,HCPCS,Outpatient,,,10,7,,0.02,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,100.32,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
HEP-LOCK 100 UNITS INJ,620751,CDM,636,RC,J1642,HCPCS,Outpatient,,,14,9.8,,0.02,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
HEPARIN 50U\ML 500 D5W,620760,CDM,636,RC,J1642,HCPCS,Outpatient,50,ML,37,25.9,,0.02,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
HEPARIN 5000U INJ,620850,CDM,636,RC,J1644,HCPCS,Outpatient,,,14,9.8,,0.29,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
"HEPARIN 25,000U/250ML INJ",620851,CDM,636,RC,J1644,HCPCS,Outpatient,50,ML,50,35,,0.29,100,,,fee schedule,100% Aetna Market fee schedule,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
HEPATITIS B VACCINE,620961,CDM,636,RC,90371,HCPCS,Outpatient,,,978,684.6,,137.89,100,,,fee schedule,100% Aetna Market fee schedule,665.04,68,,532.03,Percent of Total Billed Charges,68% of Total Billed Charges,743.28,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,489,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.93,743.28,
HEPATITIS B 5MG INJECTION,620965,CDM,636,RC,Y7506,HCPCS,Outpatient,5,ME,154,107.8,,,,,,Other,Not Seperately Reimbusable,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,135.58,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
HUMALOG 75/25 1U INJ,621001,CDM,636,RC,J1815,HCPCS,Outpatient,,,1,0.7,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,31.01,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,184.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
HUMALOG 1U INJECTION,621002,CDM,636,RC,J1815,HCPCS,Outpatient,,,1,0.7,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,274.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
HUMULIN 70/30 1U INJ,621014,CDM,636,RC,J1815,HCPCS,Outpatient,,,1,0.7,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
HUMULIN N 1U INJECTION,621015,CDM,636,RC,J1815,HCPCS,Outpatient,,,1,0.7,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
HUMULIN R 1U INJECTION,621016,CDM,636,RC,J1815,HCPCS,Outpatient,,,1,0.7,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,0.68,68,,0.54,Percent of Total Billed Charges,68% of Total Billed Charges,0.76,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,0.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,0.5,0.76,
HYDROMORPHONE 2MG INJ,621205,CDM,636,RC,J1170,HCPCS,Outpatient,2,ME,8,5.6,,5.05,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,96.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
HYDROMORPHONE 4MG INJ,621210,CDM,636,RC,J1170,HCPCS,Outpatient,4,ME,10,7,,5.05,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,76,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
HYDROMORPHONE 40MG/20ML INJ,621215,CDM,636,RC,J1170,HCPCS,Outpatient,4020,ME,37,25.9,,5.05,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
HYPERSTAT 300MG AMP INJ,621350,CDM,636,RC,J1730,HCPCS,Outpatient,300,ME,41,28.7,,104.83,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,31.16,
IMITREX 6MG/0.5ML,621764,CDM,636,RC,J3030,HCPCS,Outpatient,605,ME,351,245.7,,60.99,100,,,fee schedule,100% Aetna Market fee schedule,238.68,68,,190.94,Percent of Total Billed Charges,68% of Total Billed Charges,266.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,175.5,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.5,266.76,
IMMUNE GLOBULIN 500MG IV,621810,CDM,636,RC,J1569,HCPCS,Outpatient,500,ME,170,119,,48.57,100,,,fee schedule,100% Aetna Market fee schedule,115.6,68,,92.48,Percent of Total Billed Charges,68% of Total Billed Charges,129.2,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,85,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,129.2,
IMMUNE GLOBULIN 30GM IV,621815,CDM,636,RC,J1569,HCPCS,Outpatient,,,9593,6715.1,,48.57,100,,,fee schedule,100% Aetna Market fee schedule,6523.24,68,,5218.59,Percent of Total Billed Charges,68% of Total Billed Charges,7290.68,76,,304,Percent of Total Billed Charges,76% of Total Billed Charges,4796.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,7290.68,
INAPSINE 2.5MG-INJ,621850,CDM,636,RC,J1790,HCPCS,Outpatient,25,ME,28,19.6,,8.7,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,38.91,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,30.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
INDERAL 1MG/ML AMP INJ,622150,CDM,636,RC,J1800,HCPCS,Outpatient,1,ME,112,78.4,,8.78,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,18.24,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
INFED 50MG-INJ,622259,CDM,636,RC,J1750,HCPCS,Outpatient,50,ME,202,141.4,,19.06,100,,,fee schedule,100% Aetna Market fee schedule,137.36,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,153.52,76,,63.23,Percent of Total Billed Charges,76% of Total Billed Charges,101,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.67,100,,,Fee Schedule,100% of CMS OPPS Rate,17.67,153.52,
INFLUENZA VACCINE PEDIATRIC <3,622260,CDM,636,RC,90655,HCPCS,Outpatient,,,146,102.2,,16.3,100,,,fee schedule,100% Aetna Market fee schedule,99.28,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,110.96,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,73,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73,110.96,
INFLUENZA VIRUS 60MCG/0.5ML,622263,CDM,636,RC,Q2038,HCPCS,Outpatient,5,ML,93,65.1,,12.68,100,,,fee schedule,100% Aetna Market fee schedule,63.24,68,,50.59,Percent of Total Billed Charges,68% of Total Billed Charges,70.68,76,,41.95,Percent of Total Billed Charges,76% of Total Billed Charges,46.5,50,,38,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.5,70.68,
INVANZ 1GM INJ,622300,CDM,636,RC,J1335,HCPCS,Outpatient,,,286,200.2,,14.26,100,,,fee schedule,100% Aetna Market fee schedule,194.48,68,,155.58,Percent of Total Billed Charges,68% of Total Billed Charges,217.36,76,,4.26,Percent of Total Billed Charges,76% of Total Billed Charges,143,50,,60,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143,217.36,
INSULIN 100U/100ML INJ,622344,CDM,636,RC,J1815,HCPCS,Outpatient,100,ML,168,117.6,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,127.68,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,84,50,,4220.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,127.68,
INTEGRILIN 2MG/ML INJ (4 UNITS,622378,CDM,636,RC,J1327,HCPCS,Outpatient,24,ME,900,630,,16.89,100,,,fee schedule,100% Aetna Market fee schedule,612,68,,489.6,Percent of Total Billed Charges,68% of Total Billed Charges,684,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,450,50,,154.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,684,
INTEGRILIN 0.75MG/ML INJ(15 UN,622379,CDM,636,RC,J1327,HCPCS,Outpatient,7515,ME,1175,822.5,,16.89,100,,,fee schedule,100% Aetna Market fee schedule,799,68,,639.2,Percent of Total Billed Charges,68% of Total Billed Charges,893,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,587.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4.15,893,
IPRATROPIUM BROMIDE 0.5MG-INHA,622456,CDM,636,RC,J7644,HCPCS,Outpatient,5,ME,9,6.3,,0.36,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
TEFLARO 400MG INJ,622730,CDM,636,RC,J0712,HCPCS,Outpatient,400,ME,344,240.8,,4.22,100,,,fee schedule,100% Aetna Market fee schedule,233.92,68,,187.14,Percent of Total Billed Charges,68% of Total Billed Charges,261.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,172,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,261.44,
TEFLARO 600MG INJ,622735,CDM,636,RC,J0712,HCPCS,Outpatient,600,ME,344,240.8,,4.22,100,,,fee schedule,100% Aetna Market fee schedule,233.92,68,,187.14,Percent of Total Billed Charges,68% of Total Billed Charges,261.44,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,172,50,,426,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,261.44,
INJECTAFER 750MG,622750,CDM,636,RC,J1439,HCPCS,Outpatient,750,ME,1612,1128.4,,1.26,100,,,fee schedule,100% Aetna Market fee schedule,1096.16,68,,876.93,Percent of Total Billed Charges,68% of Total Billed Charges,1225.12,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,806,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1.1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.1,100,,,Fee Schedule,100% of CMS OPPS Rate,1.1,1225.12,
KANAMYCIN 1GM/3ML INJECTION,623391,CDM,636,RC,J1840,HCPCS,Outpatient,13,ML,61,42.7,,,,,,Other,Not Seperately Reimbusable,41.48,68,,33.18,Percent of Total Billed Charges,68% of Total Billed Charges,46.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,30.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.5,46.36,
UNASYN 1.5GM INJ,624050,CDM,636,RC,J0295,HCPCS,Outpatient,,,55,38.5,,1.95,100,,,fee schedule,100% Aetna Market fee schedule,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,115.52,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.5,41.8,
KENALOG 40MG/ML INJ,624500,CDM,636,RC,J3301,HCPCS,Outpatient,40,ME,282,197.4,,1.04,100,,,fee schedule,100% Aetna Market fee schedule,191.76,68,,153.41,Percent of Total Billed Charges,68% of Total Billed Charges,214.32,76,,69.92,Percent of Total Billed Charges,76% of Total Billed Charges,141,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141,214.32,
KETOROLAC 30MG INJ,624599,CDM,636,RC,J1885,HCPCS,Outpatient,30,ME,35,24.5,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
VITAMIN K1 1MG-INJ,624800,CDM,636,RC,J3430,HCPCS,Outpatient,11,ME,20,14,,3.19,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,52.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
LANOXIN .5MG/ML INJ,625300,CDM,636,RC,J1160,HCPCS,Outpatient,5,ME,15,10.5,,10.35,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,111.26,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,34.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
FUROSEMIDE 20MG -INJ,625900,CDM,636,RC,J1940,HCPCS,Outpatient,20,ME,14,9.8,,0.63,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,234.69,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,65.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
FUROSEMIDE 40MG-INJ,625950,CDM,636,RC,J1940,HCPCS,Outpatient,40,ME,14,9.8,,0.63,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
LEVEMIR INSULIN 1 UNIT INJ,626100,CDM,636,RC,S5553,HCPCS,Outpatient,,,2,1.4,,1.31,100,,,fee schedule,100% Aetna Market fee schedule,1.36,68,,1.09,Percent of Total Billed Charges,68% of Total Billed Charges,1.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1,50,,4.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,1.52,
LEVAQUIN PREMIXED 500MG/100ML,626158,CDM,636,RC,J1956,HCPCS,Outpatient,,,182,127.4,,1,100,,,fee schedule,100% Aetna Market fee schedule,123.76,68,,99.01,Percent of Total Billed Charges,68% of Total Billed Charges,138.32,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,91,50,,157.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91,138.32,
LEVAQUIN 750MG IV PREMIX,626159,CDM,636,RC,J1956,HCPCS,Outpatient,750,ME,294,205.8,,1,100,,,fee schedule,100% Aetna Market fee schedule,199.92,68,,159.94,Percent of Total Billed Charges,68% of Total Billed Charges,223.44,76,,647.52,Percent of Total Billed Charges,76% of Total Billed Charges,147,50,,20.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147,223.44,
LEVAQUIN 250MG IV PREMIX,626161,CDM,636,RC,J1956,HCPCS,Outpatient,250,ME,125,87.5,,1,100,,,fee schedule,100% Aetna Market fee schedule,85,68,,68,Percent of Total Billed Charges,68% of Total Billed Charges,95,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,62.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.5,95,
LEVSIN INJ .5MG/1ML-INJ,626212,CDM,636,RC,J1980,HCPCS,Outpatient,51,ME,126,88.2,,39.01,100,,,fee schedule,100% Aetna Market fee schedule,85.68,68,,68.54,Percent of Total Billed Charges,68% of Total Billed Charges,95.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,63,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63,95.76,
LIDOCAINE 100MG/5CC INJ,626600,CDM,636,RC,J2001,HCPCS,Outpatient,100,ME,35,24.5,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,548.42,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
LIDOCAINE 2G/500ML INJ,626700,CDM,636,RC,J2001,HCPCS,Outpatient,500,ML,65,45.5,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,44.2,68,,35.36,Percent of Total Billed Charges,68% of Total Billed Charges,49.4,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,32.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.5,49.4,
LIDOCAINE/10ML INJ,626750,CDM,636,RC,J2001,HCPCS,Outpatient,10,ML,9,6.3,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,183.62,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
LINCOCIN 300MG IV,626925,CDM,636,RC,J2010,HCPCS,Outpatient,300,ME,211,147.7,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,143.48,68,,114.78,Percent of Total Billed Charges,68% of Total Billed Charges,160.36,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,105.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.5,160.36,
METOPROLOL TARTRATE 5MG INJ,627254,CDM,636,RC,J3490,HCPCS,Outpatient,5,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,79.65,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
LOVENOX 60MG/0.6ML INJ,627413,CDM,636,RC,J1650,HCPCS,Outpatient,6006,ME,228,159.6,,0.75,100,,,fee schedule,100% Aetna Market fee schedule,155.04,68,,124.03,Percent of Total Billed Charges,68% of Total Billed Charges,173.28,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,114,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,173.28,
LOVENOX 80MG-INJ,627415,CDM,636,RC,J1650,HCPCS,Outpatient,80,ME,304,212.8,,0.75,100,,,fee schedule,100% Aetna Market fee schedule,206.72,68,,165.38,Percent of Total Billed Charges,68% of Total Billed Charges,231.04,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,152,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152,231.04,
LOVENOX 100MG-INJ,627416,CDM,636,RC,J1650,HCPCS,Outpatient,100,ME,379,265.3,,0.75,100,,,fee schedule,100% Aetna Market fee schedule,257.72,68,,206.18,Percent of Total Billed Charges,68% of Total Billed Charges,288.04,76,,262.66,Percent of Total Billed Charges,76% of Total Billed Charges,189.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.5,288.04,
LOVENOX 30MG/0.3ML INJ,627417,CDM,636,RC,J1650,HCPCS,Outpatient,3003,ME,129,90.3,,0.75,100,,,fee schedule,100% Aetna Market fee schedule,87.72,68,,70.18,Percent of Total Billed Charges,68% of Total Billed Charges,98.04,76,,52.29,Percent of Total Billed Charges,76% of Total Billed Charges,64.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.5,98.04,
LOVENOX 40 MG-INJ,627418,CDM,636,RC,J1650,HCPCS,Outpatient,40,ME,152,106.4,,0.75,100,,,fee schedule,100% Aetna Market fee schedule,103.36,68,,82.69,Percent of Total Billed Charges,68% of Total Billed Charges,115.52,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,76,50,,18.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76,115.52,
LUPRON DEPOT 6MT 45MG,627560,CDM,636,RC,J9217,HCPCS,Outpatient,645,ME,15759,11031.3,,199.43,100,,,fee schedule,100% Aetna Market fee schedule,10716.12,68,,8572.9,Percent of Total Billed Charges,68% of Total Billed Charges,11976.84,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7879.5,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,176.51,11976.84,
LUPRON DEPOT 3.75MG,627566,CDM,636,RC,J1950,HCPCS,Outpatient,375,ME,2851,1995.7,,1721.06,100,,,fee schedule,100% Aetna Market fee schedule,1938.68,68,,1550.94,Percent of Total Billed Charges,68% of Total Billed Charges,2166.76,76,,6.08,Percent of Total Billed Charges,76% of Total Billed Charges,1425.5,50,,170.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2183.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1425.5,2183.82,
LUPRON DEPOT 4MT 30MG,627586,CDM,636,RC,J9217,HCPCS,Outpatient,430,ME,6377,4463.9,,199.43,100,,,fee schedule,100% Aetna Market fee schedule,4336.36,68,,3469.09,Percent of Total Billed Charges,68% of Total Billed Charges,4846.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,3188.5,50,,75.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,176.51,4846.52,
LUPRON 22.5MG 3MO,627587,CDM,636,RC,J9217,HCPCS,Outpatient,2253,ME,6830,4781,,199.43,100,,,fee schedule,100% Aetna Market fee schedule,4644.4,68,,3715.52,Percent of Total Billed Charges,68% of Total Billed Charges,5190.8,76,,145.92,Percent of Total Billed Charges,76% of Total Billed Charges,3415,50,,20.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,238.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.51,100,,,Fee Schedule,100% of CMS OPPS Rate,176.51,5190.8,
LUPRON DEPO 3MO 11.25MG INJ,627588,CDM,636,RC,J1950,HCPCS,Outpatient,,,5098,3568.6,,1721.06,100,,,fee schedule,100% Aetna Market fee schedule,3466.64,68,,2773.31,Percent of Total Billed Charges,68% of Total Billed Charges,3874.48,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,2549,50,,14.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2183.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1617.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1617.65,3874.48,
MAGNESIUM SULFATE 5GM/10ML INJ,628100,CDM,636,RC,J3475,HCPCS,Outpatient,510,ML,14,9.8,,0.76,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MAGNESIUM SULFATE 40GM/1000ML,628150,CDM,636,RC,J3475,HCPCS,Outpatient,1000,ML,49,34.3,,0.76,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
MANNITOL 50CC INJ,628200,CDM,636,RC,J2150,HCPCS,Outpatient,,,14,9.8,,2.85,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,38.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MANNITOL 50GM/100ML IV,628225,CDM,636,RC,J2150,HCPCS,Outpatient,100,ML,22,15.4,,2.85,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
MARCAINE W/EPI 0.25%,628315,CDM,636,RC,J3490,HCPCS,Outpatient,,,67,46.9,,,,,,Other,Not Seperately Reimbusable,45.56,68,,36.45,Percent of Total Billed Charges,68% of Total Billed Charges,50.92,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,33.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.5,50.92,
MARCAINE W/EPI 0.5%,628320,CDM,636,RC,J3490,HCPCS,Outpatient,,,44,30.8,,,,,,Other,Not Seperately Reimbusable,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,3.04,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
MARCAINE 0.75% INJ,628333,CDM,636,RC,J3490,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,3.65,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
MAXIPIME 1GM-INJ,628406,CDM,636,RC,J0692,HCPCS,Outpatient,,,107,74.9,,1.39,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,114.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
METHYLPREDNISOLONE 4MG TAB,628647,CDM,636,RC,J7509,HCPCS,Outpatient,4,ME,8,5.6,,0.25,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
MEFOXIN 1GM INJ,628700,CDM,636,RC,J0694,HCPCS,Outpatient,,,69,48.3,,5.59,100,,,fee schedule,100% Aetna Market fee schedule,46.92,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,52.44,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,34.5,50,,386.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.5,52.44,
MEFOXIN 2GM INJ FRZ,628725,CDM,636,RC,J0694,HCPCS,Outpatient,,,37,25.9,,5.59,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
CEFOXITIN 2GR,628750,CDM,636,RC,J0694,HCPCS,Outpatient,,,135,94.5,,5.59,100,,,fee schedule,100% Aetna Market fee schedule,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,162.94,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
MEPERIDINE 25MG/ML -INJ,629170,CDM,636,RC,J2175,HCPCS,Outpatient,25,ME,14,9.8,,8.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,72.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MEPERIDINE 50MG/ML -INJ,629175,CDM,636,RC,J2175,HCPCS,Outpatient,50,ME,14,9.8,,8.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,203.07,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MEPERIDINE 75MG/ML-INJ,629180,CDM,636,RC,J2175,HCPCS,Outpatient,75,ME,14,9.8,,8.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,605.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MEPERIDINE 100MG/ML-INJ,629185,CDM,636,RC,J2175,HCPCS,Outpatient,100,ME,14,9.8,YB,8.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MERREM 500MG IV,629220,CDM,636,RC,J2185,HCPCS,Outpatient,500,ME,146,102.2,,0.5,100,,,fee schedule,100% Aetna Market fee schedule,99.28,68,,79.42,Percent of Total Billed Charges,68% of Total Billed Charges,110.96,76,,46.21,Percent of Total Billed Charges,76% of Total Billed Charges,73,50,,364.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73,110.96,
MERREM 1GM INJ,629225,CDM,636,RC,J2185,HCPCS,Outpatient,,,330,231,,0.5,100,,,fee schedule,100% Aetna Market fee schedule,224.4,68,,179.52,Percent of Total Billed Charges,68% of Total Billed Charges,250.8,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,165,50,,364.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,250.8,
METHERGINE 0.2MG INJ,629450,CDM,636,RC,J2210,HCPCS,Outpatient,2,ME,35,24.5,,21.56,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
METHOTREXATE 2.5MG TABLET,629570,CDM,636,RC,J8610,HCPCS,Outpatient,25,ME,35,24.5,,0.29,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
METHYLENE BLUE INJ.,629579,CDM,636,RC,,,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,23.1,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,99.2,Percent of Total Billed Charges,50% of Total Billed Charges,8.45,65,,6.76,Percent of Total Billed Charges,65% of Total Billed Charges,9.75,75,,7.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,7.8,60,,6.24,Percent of Total Billed Charges,60% of Total Billed Charges,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.65,20.4,,2.12,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.6,20,,2.08,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.6,9.88,
POTASSIUM ACETATE 40MEQ/20ML I,629600,CDM,636,RC,Y7506,HCPCS,Outpatient,4020,ML,35,24.5,,,,,,Other,Not Seperately Reimbusable,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
MIDAZOLAM 50MG/10ML INJ,629672,CDM,636,RC,J2250,HCPCS,Outpatient,5010,ME,102,71.4,,0.16,100,,,fee schedule,100% Aetna Market fee schedule,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,27.97,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51,77.52,
MILRINONE 20MG/100ML INJ,629710,CDM,636,RC,J2260,HCPCS,Outpatient,,,85,59.5,,1.72,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,259.01,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
"MEASLES, MUMPS & RUBELLA 0.5ML",629996,CDM,636,RC,90708,HCPCS,Outpatient,5,ML,251,175.7,,,,,,Other,Not Seperately Reimbusable,170.68,68,,136.54,Percent of Total Billed Charges,68% of Total Billed Charges,190.76,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,125.5,50,,140,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.5,190.76,
MITOMYCIN 20MG INJ,630025,CDM,636,RC,J9280,HCPCS,Outpatient,20,ME,962,673.4,,69.68,100,,,fee schedule,100% Aetna Market fee schedule,654.16,68,,523.33,Percent of Total Billed Charges,68% of Total Billed Charges,731.12,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,481,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.51,731.12,
MICAFUNGIN 100MG IV,630101,CDM,636,RC,J2248,HCPCS,Outpatient,100,ME,748,523.6,,0.83,100,,,fee schedule,100% Aetna Market fee schedule,508.64,68,,406.91,Percent of Total Billed Charges,68% of Total Billed Charges,568.48,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,374,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,374,568.48,
DAPTOMYCIN 350MG IV,630102,CDM,636,RC,J0878,HCPCS,Outpatient,350,ME,208,145.6,,0.04,100,,,fee schedule,100% Aetna Market fee schedule,141.44,68,,113.15,Percent of Total Billed Charges,68% of Total Billed Charges,158.08,76,,255.36,Percent of Total Billed Charges,76% of Total Billed Charges,104,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104,158.08,
MORPHINE SULFATE INJ 10MG/ML,630200,CDM,636,RC,J2270,HCPCS,Outpatient,10,ME,14,9.8,YA,5.13,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MORPHINE SULFATE 2MG/ML-INJ,630202,CDM,636,RC,J2270,HCPCS,Outpatient,2,ME,14,9.8,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,34.66,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MORPHINE SULFATE 4MG/ML-INJ,630203,CDM,636,RC,J2270,HCPCS,Outpatient,4,ME,14,9.8,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,580.64,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
MORPHINE 5MG INH SDV,630204,CDM,636,RC,J2270,HCPCS,Outpatient,5,ME,13,9.1,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,83.9,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
MORPHINE 10MG INJ SDV,630205,CDM,636,RC,J2270,HCPCS,Outpatient,10,ME,13,9.1,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,1028.74,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,132.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
MORPHINE SULFATE 15MG/ML-INJ,630220,CDM,636,RC,J2270,HCPCS,Outpatient,15,ME,8,5.6,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
ARANESP 40MCG/ML INJ,630953,CDM,636,RC,J0882,HCPCS,Outpatient,40,ML,1087,760.9,,3.22,100,,,fee schedule,100% Aetna Market fee schedule,739.16,68,,591.33,Percent of Total Billed Charges,68% of Total Billed Charges,826.12,76,,213.41,Percent of Total Billed Charges,76% of Total Billed Charges,543.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.04,826.12,
MIOCHOL-E INJ 20MJ,631500,CDM,636,RC,,,Outpatient,,,246,172.2,,,,,,Other,Not Seperately Reimbusable,167.28,68,,133.82,Percent of Total Billed Charges,68% of Total Billed Charges,186.96,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,123,50,,79.2,Percent of Total Billed Charges,50% of Total Billed Charges,159.9,65,,127.92,Percent of Total Billed Charges,65% of Total Billed Charges,184.5,75,,147.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,147.6,60,,118.08,Percent of Total Billed Charges,60% of Total Billed Charges,50.18,20.4,,40.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,50.18,20.4,,40.14,Percent of Total Billed Charges,20.4% of Total Billed Charges,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.2,20,,39.36,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,49.2,186.96,
NANDROLONE DEC INJ 100MG,631875,CDM,636,RC,J2321,HCPCS,Outpatient,100,ME,97,67.9,,,,,,Other,Not Seperately Reimbusable,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,73.72,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,48.5,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.5,73.72,
NAROPIN 2MG/ML 20ML INJ,632098,CDM,636,RC,J2795,HCPCS,Outpatient,220,ME,58,40.6,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,128.29,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,44.08,
NAROPIN 2MG/ML 200ML INJ,632099,CDM,636,RC,J2795,HCPCS,Outpatient,2200,ME,429,300.3,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,291.72,68,,233.38,Percent of Total Billed Charges,68% of Total Billed Charges,326.04,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,214.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.5,326.04,
NARCAN 0.4MG INJ,632100,CDM,636,RC,J2310,HCPCS,Outpatient,4,ME,25,17.5,,8.02,100,,,fee schedule,100% Aetna Market fee schedule,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,20.13,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
NAROPIN 2MG/ML 100ML INJ,632101,CDM,636,RC,J2795,HCPCS,Outpatient,2100,ME,120,84,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,81.6,68,,65.28,Percent of Total Billed Charges,68% of Total Billed Charges,91.2,76,,823.07,Percent of Total Billed Charges,76% of Total Billed Charges,60,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60,91.2,
NAROPIN 5MG/ML 30ML INJ,632103,CDM,636,RC,J2795,HCPCS,Outpatient,530,ME,96,67.2,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
NAROPIN 10MG/ML 20ML INJ,632104,CDM,636,RC,J2795,HCPCS,Outpatient,1020,ME,96,67.2,,0.08,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
TOBRAMYCIN 80MG INJ,632150,CDM,636,RC,J3260,HCPCS,Outpatient,80,ME,16,11.2,,2.93,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
NATRECOR 1.5MG INJ,632200,CDM,636,RC,J2325,HCPCS,Outpatient,15,ME,2822,1975.4,,68.59,100,,,fee schedule,100% Aetna Market fee schedule,1918.96,68,,1535.17,Percent of Total Billed Charges,68% of Total Billed Charges,2144.72,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,1411,50,,99.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1411,2144.72,
NEUPOGEN 300MCG/1.0ML INJ,633148,CDM,636,RC,J1442,HCPCS,Outpatient,30010,ML,1195,836.5,,1.08,100,,,fee schedule,100% Aetna Market fee schedule,812.6,68,,650.08,Percent of Total Billed Charges,68% of Total Billed Charges,908.2,76,,544,Percent of Total Billed Charges,76% of Total Billed Charges,597.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS Rate,1,908.2,
NEUPOGEN 480 MCG INJ,633151,CDM,636,RC,J1442,HCPCS,Outpatient,,,1903,1332.1,,1.08,100,,,fee schedule,100% Aetna Market fee schedule,1294.04,68,,1035.23,Percent of Total Billed Charges,68% of Total Billed Charges,1446.28,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,951.5,50,,302,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,100,,,Fee Schedule,100% of CMS OPPS Rate,1,1446.28,
NEULASTA 6MG INJ,633155,CDM,636,RC,J2505,HCPCS,Outpatient,6,ME,8662,6063.4,,,,,,Other,Not Seperately Reimbusable,5890.16,68,,4712.13,Percent of Total Billed Charges,68% of Total Billed Charges,6583.12,76,,496.13,Percent of Total Billed Charges,76% of Total Billed Charges,4331,50,,302,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4331,6583.12,
NICARDIPINE 25MG/10ML INJ,633230,CDM,636,RC,J3490,HCPCS,Outpatient,2510,ME,119,83.3,,,,,,Other,Not Seperately Reimbusable,80.92,68,,64.74,Percent of Total Billed Charges,68% of Total Billed Charges,90.44,76,,302.46,Percent of Total Billed Charges,76% of Total Billed Charges,59.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.5,90.44,
NITROGLYCERIN 200MCG/ML INJ,633557,CDM,636,RC,J3490,HCPCS,Outpatient,200,ML,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,55.48,
NITROGLYCERIN 50MG/10ML INJ,633575,CDM,636,RC,J3490,HCPCS,Outpatient,5010,ME,73,51.1,,,,,,Other,Not Seperately Reimbusable,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,55.48,
NORFLEX INJ 60MG/2ML,633748,CDM,636,RC,J2360,HCPCS,Outpatient,602,ME,135,94.5,,10.68,100,,,fee schedule,100% Aetna Market fee schedule,91.8,68,,73.44,Percent of Total Billed Charges,68% of Total Billed Charges,102.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,67.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.5,102.6,
NORMAL SALINE 100ML MINIBAGP I,633763,CDM,636,RC,J7050,HCPCS,Outpatient,100,ML,80,56,,0.74,100,,,fee schedule,100% Aetna Market fee schedule,54.4,68,,43.52,Percent of Total Billed Charges,68% of Total Billed Charges,60.8,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,40,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40,60.8,
NS 0.45% /20MEQ 1000ML,633770,CDM,636,RC,J3480,HCPCS,Outpatient,1000,ML,35,24.5,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
NALBUPHINE 10MG INJ,634222,CDM,636,RC,J2300,HCPCS,Outpatient,10,ME,14,9.8,,3.09,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
NALBUPHINE 20MG INJ,634224,CDM,636,RC,J2300,HCPCS,Outpatient,20,ME,14,9.8,,3.09,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,249.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
OCTAGAM 10GM,634375,CDM,636,RC,J1569,HCPCS,Outpatient,,,2225,1557.5,,48.57,100,,,fee schedule,100% Aetna Market fee schedule,1513,68,,1210.4,Percent of Total Billed Charges,68% of Total Billed Charges,1691,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,1112.5,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,100,,,Fee Schedule,100% of CMS OPPS Rate,49.69,1691,
OFIRMEV 1000MG/100ML INJ,634400,CDM,636,RC,J0131,HCPCS,Outpatient,,,160,112,,0.05,100,,,fee schedule,100% Aetna Market fee schedule,108.8,68,,87.04,Percent of Total Billed Charges,68% of Total Billed Charges,121.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,80,50,,154,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80,121.6,
KEYTRUDA 100MG,634988,CDM,636,RC,J9271,HCPCS,Outpatient,100,ME,7253,5077.1,,61.3,100,,,fee schedule,100% Aetna Market fee schedule,4932.04,68,,3945.63,Percent of Total Billed Charges,68% of Total Billed Charges,5512.28,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,3626.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.22,100,,,Fee Schedule,100% of CMS OPPS Rate,58.22,5512.28,
OXACILLIN 500MG INJ,635015,CDM,636,RC,J2700,HCPCS,Outpatient,500,ME,10,7,,1.15,100,,,fee schedule,100% Aetna Market fee schedule,6.8,68,,5.44,Percent of Total Billed Charges,68% of Total Billed Charges,7.6,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,5,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5,7.6,
OXACILLIN 2GM IV,635020,CDM,636,RC,J2700,HCPCS,Outpatient,,,113,79.1,,1.15,100,,,fee schedule,100% Aetna Market fee schedule,76.84,68,,61.47,Percent of Total Billed Charges,68% of Total Billed Charges,85.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,56.5,50,,93.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.5,85.88,
PAMIDRONATE 30MG INJ,635150,CDM,636,RC,J2430,HCPCS,Outpatient,30,ME,172,120.4,,20.59,100,,,fee schedule,100% Aetna Market fee schedule,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86,130.72,
PCA MORPHINE IV 1MG/ML-30ML-IN,635784,CDM,636,RC,J2274,HCPCS,Outpatient,130,ME,46,32.2,,12.37,100,,,fee schedule,100% Aetna Market fee schedule,31.28,68,,25.02,Percent of Total Billed Charges,68% of Total Billed Charges,34.96,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,23,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23,34.96,
MEPERIDINE PCA 10MG/ML-INJ,635820,CDM,636,RC,J2175,HCPCS,Outpatient,10,ME,72,50.4,,8.03,100,,,fee schedule,100% Aetna Market fee schedule,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,187.14,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36,54.72,
PEN. GK 5 MIL UNITS INJ,636050,CDM,636,RC,J2540,HCPCS,Outpatient,,,68,47.6,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,46.24,68,,36.99,Percent of Total Billed Charges,68% of Total Billed Charges,51.68,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,34,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34,51.68,
PENICILLIN G POTASSIUM 20MIL U,636140,CDM,636,RC,J2540,HCPCS,Outpatient,,,63,44.1,,0.85,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
PENTOTHAL 500MG INJ,636411,CDM,636,RC,Y7506,HCPCS,Outpatient,500,ME,118,82.6,,,,,,Other,Not Seperately Reimbusable,80.24,68,,64.19,Percent of Total Billed Charges,68% of Total Billed Charges,89.68,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,59,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59,89.68,
PEPCID 20MG/2ML IV INJ,636431,CDM,636,RC,J3490,HCPCS,Outpatient,202,ME,20,14,,,,,,Other,Not Seperately Reimbusable,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
PROMETHAZINE 25MG-INJ,637600,CDM,636,RC,J2550,HCPCS,Outpatient,25,ME,16,11.2,,3.95,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
PHENOBARB 65MG INJ,638200,CDM,636,RC,J2560,HCPCS,Outpatient,65,ME,112,78.4,,34.58,100,,,fee schedule,100% Aetna Market fee schedule,76.16,68,,60.93,Percent of Total Billed Charges,68% of Total Billed Charges,85.12,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,56,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56,85.12,
PHENOBARB 130MG INJ,638250,CDM,636,RC,J2560,HCPCS,Outpatient,130,ME,259,181.3,,34.58,100,,,fee schedule,100% Aetna Market fee schedule,176.12,68,,140.9,Percent of Total Billed Charges,68% of Total Billed Charges,196.84,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,129.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.5,196.84,
PHENYTOIN 100MG INJ,638255,CDM,636,RC,J1165,HCPCS,Outpatient,100,ME,13,9.1,,0.69,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
PHENYTOIN SODIUM 250MG VIAL,638260,CDM,636,RC,J1165,HCPCS,Outpatient,250,ME,14,9.8,,0.69,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
OXYTOCIN UP TO 10 UNITS INJ,638450,CDM,636,RC,J2590,HCPCS,Outpatient,,,21,14.7,,1.36,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,410.72,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,15.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
PNEUMOCOCCAL VACCINE,638476,CDM,636,RC,90732,HCPCS,Outpatient,,,73,51.1,,133.47,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,107.71,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.5,55.48,
PNEUMOCOCCAL VACCINE INJ,638477,CDM,636,RC,S0195,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,99.96,68,,79.97,Percent of Total Billed Charges,68% of Total Billed Charges,111.72,76,,134.91,Percent of Total Billed Charges,76% of Total Billed Charges,73.5,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.5,111.72,
POTASSIUM CHLORIDE 40MEQ-INJ,639200,CDM,636,RC,J3480,HCPCS,Outpatient,,,14,9.8,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,181.7,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,423.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PREMARIN 25MG INJ,639605,CDM,636,RC,J1410,HCPCS,Outpatient,25,ME,83,58.1,,409.36,100,,,fee schedule,100% Aetna Market fee schedule,56.44,68,,45.15,Percent of Total Billed Charges,68% of Total Billed Charges,63.08,76,,209.44,Percent of Total Billed Charges,76% of Total Billed Charges,41.5,50,,80.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.79,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,516.76,
PREVACID 30MG INJ,639706,CDM,636,RC,,,Outpatient,30,ME,150,105,,,,,,Other,Not Seperately Reimbusable,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,1661.92,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,27.2,Percent of Total Billed Charges,50% of Total Billed Charges,97.5,65,,78,Percent of Total Billed Charges,65% of Total Billed Charges,112.5,75,,90,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,90,60,,72,Percent of Total Billed Charges,60% of Total Billed Charges,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30.6,20.4,,24.48,Percent of Total Billed Charges,20.4% of Total Billed Charges,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,20,,24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,30,114,
PRIMAXIN 250MG IV,639720,CDM,636,RC,J0743,HCPCS,Outpatient,250,ME,113,79.1,,8.91,100,,,fee schedule,100% Aetna Market fee schedule,76.84,68,,61.47,Percent of Total Billed Charges,68% of Total Billed Charges,85.88,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,56.5,50,,46.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.5,85.88,
PRIMAXIN 500MG-INJ,639721,CDM,636,RC,J0743,HCPCS,Outpatient,500,ME,185,129.5,,8.91,100,,,fee schedule,100% Aetna Market fee schedule,125.8,68,,100.64,Percent of Total Billed Charges,68% of Total Billed Charges,140.6,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,92.5,50,,53.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.5,140.6,
EPOGEN 4000 U INJ,640067,CDM,636,RC,J0885,HCPCS,Outpatient,,,300,210,,9.77,100,,,fee schedule,100% Aetna Market fee schedule,204,68,,163.2,Percent of Total Billed Charges,68% of Total Billed Charges,228,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,150,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.53,228,
PROGESTERONE 50MG/ML INJ,640110,CDM,636,RC,J2675,HCPCS,Outpatient,50,ME,32,22.4,,1.01,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,24.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
PROLIA 60MG INJ,640151,CDM,636,RC,J0897,HCPCS,Outpatient,60,ME,2178,1524.6,,27.72,100,,,fee schedule,100% Aetna Market fee schedule,1481.04,68,,1184.83,Percent of Total Billed Charges,68% of Total Billed Charges,1655.28,76,,175.71,Percent of Total Billed Charges,76% of Total Billed Charges,1089,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.96,100,,,Fee Schedule,100% of CMS OPPS Rate,26.96,1655.28,
PRONESTYL 100MG/CC-INJ,640350,CDM,636,RC,J2690,HCPCS,Outpatient,100,ME,35,24.5,,160.95,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,42.56,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,9.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,737.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.07,100,,,Fee Schedule,100% of CMS OPPS Rate,17.5,737.19,
PROPOFOL 1% 100ML,640400,CDM,636,RC,J2704,HCPCS,Outpatient,100,ML,144,100.8,,0.14,100,,,fee schedule,100% Aetna Market fee schedule,97.92,68,,78.34,Percent of Total Billed Charges,68% of Total Billed Charges,109.44,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,72,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,109.44,
PROTAMINE SULFATE 10MG INJ,640505,CDM,636,RC,J2720,HCPCS,Outpatient,10,ME,14,9.8,,1.82,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
PROTOPAM CHLORIDE 1G INJ,640520,CDM,636,RC,J2730,HCPCS,Outpatient,,,578,404.6,,84.27,100,,,fee schedule,100% Aetna Market fee schedule,393.04,68,,314.43,Percent of Total Billed Charges,68% of Total Billed Charges,439.28,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,289,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289,439.28,
PROVENGE 50MU 250ML INJ,640550,CDM,636,RC,Q2043,HCPCS,Outpatient,50,ML,50473,35331.1,,58769.32,100,,,fee schedule,100% Aetna Market fee schedule,34321.64,68,,27457.31,Percent of Total Billed Charges,68% of Total Billed Charges,38359.48,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,25236.5,50,,4.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74270.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55015.23,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55015.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55015.23,100,,,Fee Schedule,100% of CMS OPPS Rate,25236.5,74270.56,
RECLAST 1MG INFUSION,640950,CDM,636,RC,J3488,HCPCS,Outpatient,1,ME,2363,1654.1,,,,,,Other,Not Seperately Reimbusable,1606.84,68,,1285.47,Percent of Total Billed Charges,68% of Total Billed Charges,1795.88,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1181.5,50,,42.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1181.5,1795.88,
RECLAST 5MG IV,640960,CDM,636,RC,J3489,HCPCS,Outpatient,5,ME,3151,2205.7,,7.93,100,,,fee schedule,100% Aetna Market fee schedule,2142.68,68,,1714.14,Percent of Total Billed Charges,68% of Total Billed Charges,2394.76,76,,6.69,Percent of Total Billed Charges,76% of Total Billed Charges,1575.5,50,,34,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1575.5,2394.76,
REGLAN 10MG/2ML INJ,641714,CDM,636,RC,J2765,HCPCS,Outpatient,102,ME,15,10.5,,1.2,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
METOCLOPRAMIDE HCL 10MG-INJ,641715,CDM,636,RC,J2765,HCPCS,Outpatient,10,ME,14,9.8,,1.2,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
REMICADE 100MG INJ,641750,CDM,636,RC,J1745,HCPCS,Outpatient,100,ME,1875,1312.5,,35.38,100,,,fee schedule,100% Aetna Market fee schedule,1275,68,,1020,Percent of Total Billed Charges,68% of Total Billed Charges,1425,76,,19.46,Percent of Total Billed Charges,76% of Total Billed Charges,937.5,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.22,100,,,Fee Schedule,100% of CMS OPPS Rate,32.22,1425,
REMDESIVIR 100 MG INJ,641802,CDM,636,RC,J0248,HCPCS,Outpatient,100,ME,1020,714,,5.51,100,,,fee schedule,100% Aetna Market fee schedule,693.6,68,,554.88,Percent of Total Billed Charges,68% of Total Billed Charges,775.2,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,510,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.35,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.35,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,775.2,
RHO(D) IMMUNE GLOBULIN 300MG I,642168,CDM,636,RC,J2792,HCPCS,Outpatient,300,ME,586,410.2,,36.26,100,,,fee schedule,100% Aetna Market fee schedule,398.48,68,,318.78,Percent of Total Billed Charges,68% of Total Billed Charges,445.36,76,,15.2,Percent of Total Billed Charges,76% of Total Billed Charges,293,50,,159.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,445.36,
RHO (D) IMMUNE GLOB-120MCG INJ,642169,CDM,636,RC,J2792,HCPCS,Outpatient,,,743,520.1,,36.26,100,,,fee schedule,100% Aetna Market fee schedule,505.24,68,,404.19,Percent of Total Billed Charges,68% of Total Billed Charges,564.68,76,,8.51,Percent of Total Billed Charges,76% of Total Billed Charges,371.5,50,,133.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,100,,,Fee Schedule,100% of CMS OPPS Rate,34.34,564.68,
RIMSO-50 54GM,642250,CDM,636,RC,J1212,HCPCS,Outpatient,,,2729,1910.3,,748.9,100,,,fee schedule,100% Aetna Market fee schedule,1855.72,68,,1484.58,Percent of Total Billed Charges,68% of Total Billed Charges,2074.04,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,1364.5,50,,80.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,966.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,715.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,715.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,715.9,100,,,Fee Schedule,100% of CMS OPPS Rate,715.9,2074.04,
RISPERDAL CONSTA 25MG INJ,642384,CDM,636,RC,J2794,HCPCS,Outpatient,25,ME,1088,761.6,,13.37,100,,,fee schedule,100% Aetna Market fee schedule,739.84,68,,591.87,Percent of Total Billed Charges,68% of Total Billed Charges,826.88,76,,643.26,Percent of Total Billed Charges,76% of Total Billed Charges,544,50,,141.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,826.88,
RISPERDAL CONSTA 37.5MG INJ,642385,CDM,636,RC,J2794,HCPCS,Outpatient,375,ME,1633,1143.1,,13.37,100,,,fee schedule,100% Aetna Market fee schedule,1110.44,68,,888.35,Percent of Total Billed Charges,68% of Total Billed Charges,1241.08,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,816.5,50,,72,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,1241.08,
RISPERDAL CONSTA 50MG INJ,642386,CDM,636,RC,J2794,HCPCS,Outpatient,50,ME,1633,1143.1,,13.37,100,,,fee schedule,100% Aetna Market fee schedule,1110.44,68,,888.35,Percent of Total Billed Charges,68% of Total Billed Charges,1241.08,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,816.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,1241.08,
ROBAXIN 1000MG/10CC-INJ,642600,CDM,636,RC,J2800,HCPCS,Outpatient,,,99,69.3,,6.22,100,,,fee schedule,100% Aetna Market fee schedule,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,75.24,76,,41.34,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.5,75.24,
ROCEPHIN 250MG-INJ,643354,CDM,636,RC,J0696,HCPCS,Outpatient,250,ME,99,69.3,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,67.32,68,,53.86,Percent of Total Billed Charges,68% of Total Billed Charges,75.24,76,,37.09,Percent of Total Billed Charges,76% of Total Billed Charges,49.5,50,,70.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.5,75.24,
ROCEPHIN 500MG-INJ,643362,CDM,636,RC,J0696,HCPCS,Outpatient,500,ME,159,111.3,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,35.26,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,120.84,
CEFTRIAXONE ADDVANT 1GM INJ,643371,CDM,636,RC,J0696,HCPCS,Outpatient,,,134,93.8,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,91.12,68,,72.9,Percent of Total Billed Charges,68% of Total Billed Charges,101.84,76,,142.27,Percent of Total Billed Charges,76% of Total Billed Charges,67,50,,627.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67,101.84,
CEFTRIAXONE 1GM INJ,643372,CDM,636,RC,J0696,HCPCS,Outpatient,,,22,15.4,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,122.21,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
CEFTRIAXONE 1GM PREMIX,643373,CDM,636,RC,J0696,HCPCS,Outpatient,,,150,105,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,102,68,,81.6,Percent of Total Billed Charges,68% of Total Billed Charges,114,76,,72.96,Percent of Total Billed Charges,76% of Total Billed Charges,75,50,,63.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,114,
ROCEPHIN 2GM-INJ,643375,CDM,636,RC,J0696,HCPCS,Outpatient,,,556,389.2,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,378.08,68,,302.46,Percent of Total Billed Charges,68% of Total Billed Charges,422.56,76,,324.06,Percent of Total Billed Charges,76% of Total Billed Charges,278,50,,72,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278,422.56,
ROMAZICON 0.5MG/5ML-INJ,643377,CDM,636,RC,J3490,HCPCS,Outpatient,55,ME,473,331.1,,,,,,Other,Not Seperately Reimbusable,321.64,68,,257.31,Percent of Total Billed Charges,68% of Total Billed Charges,359.48,76,,141.66,Percent of Total Billed Charges,76% of Total Billed Charges,236.5,50,,51.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.5,359.48,
SANDIMMUNE 25MG CAP,643850,CDM,636,RC,J7515,HCPCS,Outpatient,25,ME,13,9.1,,0.92,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,116.13,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,57.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
SANDOSTANTIN 100MCG/ML-INJ,643900,CDM,636,RC,J2354,HCPCS,Outpatient,100,ML,145,101.5,,1.31,100,,,fee schedule,100% Aetna Market fee schedule,98.6,68,,78.88,Percent of Total Billed Charges,68% of Total Billed Charges,110.2,76,,260.22,Percent of Total Billed Charges,76% of Total Billed Charges,72.5,50,,41.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.5,110.2,
SANDOSTATIN  200MCG MDV,643925,CDM,636,RC,J2354,HCPCS,Outpatient,,,245,171.5,,1.31,100,,,fee schedule,100% Aetna Market fee schedule,166.6,68,,133.28,Percent of Total Billed Charges,68% of Total Billed Charges,186.2,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,122.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.5,186.2,
SODIUM CHLORIDE 3% 500ML INJ,645225,CDM,636,RC,,,Outpatient,500,ML,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,1.22,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,32,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
SOLU CORTEF 100MG-INJ,645500,CDM,636,RC,J1720,HCPCS,Outpatient,100,ME,16,11.2,,19.63,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SOLU CORTEF 250MG-INJ,645550,CDM,636,RC,J1720,HCPCS,Outpatient,250,ME,28,19.6,YA,19.63,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
SOLU MEDROL 1GR INJ,645648,CDM,636,RC,J2930,HCPCS,Outpatient,,,128,89.6,,,,,,Other,Not Seperately Reimbusable,87.04,68,,69.63,Percent of Total Billed Charges,68% of Total Billed Charges,97.28,76,,7.3,Percent of Total Billed Charges,76% of Total Billed Charges,64,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64,97.28,
SOLU MEDROL 40MG-INJ,645650,CDM,636,RC,J2919,HCPCS,Outpatient,40,ME,16,11.2,,,,,,Other,Not Seperately Reimbusable,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,192.13,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
SOLU MEDROL 125MG-INJ,645700,CDM,636,RC,J2919,HCPCS,Outpatient,125,ME,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,16.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
SOLU MEDROL 500MG-INJ,645750,CDM,636,RC,J2930,HCPCS,Outpatient,500,ME,63,44.1,YA,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
SPORANOX 250MG/25ML INJ,646090,CDM,636,RC,J1835,HCPCS,Outpatient,250,ME,238,166.6,,40.39,100,,,fee schedule,100% Aetna Market fee schedule,161.84,68,,129.47,Percent of Total Billed Charges,68% of Total Billed Charges,180.88,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,119,50,,12.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119,180.88,
STADOL 2MG-INJ,646100,CDM,636,RC,J0595,HCPCS,Outpatient,2,ME,57,39.9,,3.08,100,,,fee schedule,100% Aetna Market fee schedule,38.76,68,,31.01,Percent of Total Billed Charges,68% of Total Billed Charges,43.32,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,28.5,50,,29.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.5,43.32,
STERILE WATER 10ML INJ SDV,646171,CDM,636,RC,,,Outpatient,10,ML,5,3.5,,,,,,Other,Not Seperately Reimbusable,3.4,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,3.8,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,2.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,3.25,65,,2.6,Percent of Total Billed Charges,65% of Total Billed Charges,3.75,75,,3,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,3,60,,2.4,Percent of Total Billed Charges,60% of Total Billed Charges,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1.02,20.4,,0.82,Percent of Total Billed Charges,20.4% of Total Billed Charges,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1,20,,0.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1,3.8,
"STREPTOKINASE 250,000I.U. INJ",646180,CDM,636,RC,J2995,HCPCS,Outpatient,,,711,497.7,,75.94,100,,,fee schedule,100% Aetna Market fee schedule,483.48,68,,386.78,Percent of Total Billed Charges,68% of Total Billed Charges,540.36,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,355.5,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.5,540.36,
STERILE WATER 50ML INJ,646250,CDM,636,RC,A4217,HCPCS,Outpatient,50,ML,7,4.9,,1.2,100,,,fee schedule,100% Aetna Market fee schedule,4.76,68,,3.81,Percent of Total Billed Charges,68% of Total Billed Charges,5.32,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,3.5,50,,61.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.5,5.32,
FENTANYL 250MCG/5ML-INJ,646500,CDM,636,RC,J3010,HCPCS,Outpatient,5,ML,8,5.6,,1.06,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,62,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
FENTANYL 100MCG/2ML-INJ,646504,CDM,636,RC,J3010,HCPCS,Outpatient,1002,ML,15,10.5,,1.06,100,,,fee schedule,100% Aetna Market fee schedule,10.2,68,,8.16,Percent of Total Billed Charges,68% of Total Billed Charges,11.4,76,,505.86,Percent of Total Billed Charges,76% of Total Billed Charges,7.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.5,11.4,
SUCCINYLCHOLINE 20MG/ML INJ,646518,CDM,636,RC,J0330,HCPCS,Outpatient,20,ME,104,72.8,,0.79,100,,,fee schedule,100% Aetna Market fee schedule,70.72,68,,56.58,Percent of Total Billed Charges,68% of Total Billed Charges,79.04,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,52,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52,79.04,
SUFENTANIL 50MCG/ML INJECTION,646576,CDM,636,RC,J3010,HCPCS,Outpatient,50,ML,69,48.3,,1.06,100,,,fee schedule,100% Aetna Market fee schedule,46.92,68,,37.54,Percent of Total Billed Charges,68% of Total Billed Charges,52.44,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,34.5,50,,124.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.5,52.44,
TAZIDIME 2GM INJ,648990,CDM,636,RC,J0713,HCPCS,Outpatient,,,154,107.8,,1.86,100,,,fee schedule,100% Aetna Market fee schedule,104.72,68,,83.78,Percent of Total Billed Charges,68% of Total Billed Charges,117.04,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,77,50,,54,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77,117.04,
TETANUS TOXOID,649345,CDM,636,RC,90703,HCPCS,Outpatient,,,106,74.2,,,,,,Other,Not Seperately Reimbusable,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,103.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53,80.56,
TETANUS & DIPTHERIA TOX ADULT,649350,CDM,636,RC,90714,HCPCS,Outpatient,,,106,74.2,,30.34,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,103.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53,80.56,
TETANUS IMMUNE GLOBULIN 250 UN,649352,CDM,636,RC,J1670,HCPCS,Outpatient,,,700,490,,636.47,100,,,fee schedule,100% Aetna Market fee schedule,476,68,,380.8,Percent of Total Billed Charges,68% of Total Billed Charges,532,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,350,50,,103.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,350,785.4,
ADACEL 0.5MG INJ,649353,CDM,636,RC,90715,HCPCS,Outpatient,5,ME,203,142.1,,38.31,100,,,fee schedule,100% Aetna Market fee schedule,138.04,68,,110.43,Percent of Total Billed Charges,68% of Total Billed Charges,154.28,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,101.5,50,,103.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.5,154.28,
THIAMINE 100MG INJ,650150,CDM,636,RC,J3411,HCPCS,Outpatient,100,ME,16,11.2,,2.7,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,165.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
CHLORPROMAZINE 50MG INJ,650200,CDM,636,RC,J3230,HCPCS,Outpatient,50,ME,32,22.4,,32.76,100,,,fee schedule,100% Aetna Market fee schedule,21.76,68,,17.41,Percent of Total Billed Charges,68% of Total Billed Charges,24.32,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,16,50,,165.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16,24.32,
UNASYN 3GM-INJ,651115,CDM,636,RC,J0295,HCPCS,Outpatient,,,95,66.5,,1.95,100,,,fee schedule,100% Aetna Market fee schedule,64.6,68,,51.68,Percent of Total Billed Charges,68% of Total Billed Charges,72.2,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,47.5,50,,44.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.5,72.2,
TENECTEPLASE 50MG INJECTION,651305,CDM,636,RC,J3101,HCPCS,Outpatient,50,ME,10551,7385.7,,168.43,100,,,fee schedule,100% Aetna Market fee schedule,7174.68,68,,5739.74,Percent of Total Billed Charges,68% of Total Billed Charges,8018.76,76,,29.92,Percent of Total Billed Charges,76% of Total Billed Charges,5275.5,50,,42,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.72,100,,,Fee Schedule,100% of CMS OPPS Rate,157.72,8018.76,
FENTANYL 500 MCG INJ,651692,CDM,636,RC,J3010,HCPCS,Outpatient,,,20,14,,1.06,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,21.76,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,122.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
KETOROLAC 60MG INJ,651693,CDM,636,RC,J1885,HCPCS,Outpatient,60,ME,31,21.7,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,32.64,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
TRANDATE 5MG -INJ,651871,CDM,636,RC,,,Outpatient,5,ME,14,9.8,,,,,,Other,Not Seperately Reimbusable,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,34.27,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,181.6,Percent of Total Billed Charges,50% of Total Billed Charges,9.1,65,,7.28,Percent of Total Billed Charges,65% of Total Billed Charges,10.5,75,,8.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,8.4,60,,6.72,Percent of Total Billed Charges,60% of Total Billed Charges,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.86,20.4,,2.29,Percent of Total Billed Charges,20.4% of Total Billed Charges,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.8,20,,2.24,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,2.8,10.64,
ACETADOTE 100MG INJ,653100,CDM,636,RC,J0132,HCPCS,Outpatient,100,ME,902,631.4,,0.77,100,,,fee schedule,100% Aetna Market fee schedule,613.36,68,,490.69,Percent of Total Billed Charges,68% of Total Billed Charges,685.52,76,,22.85,Percent of Total Billed Charges,76% of Total Billed Charges,451,50,,167.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451,685.52,
TYGACIL 50MG INJ,653125,CDM,636,RC,J3243,HCPCS,Outpatient,50,ME,302,211.4,,0.81,100,,,fee schedule,100% Aetna Market fee schedule,205.36,68,,164.29,Percent of Total Billed Charges,68% of Total Billed Charges,229.52,76,,40.8,Percent of Total Billed Charges,76% of Total Billed Charges,151,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,229.52,
"ABBOKINASE 5,000 IU INJ",653934,CDM,636,RC,J3364,HCPCS,Outpatient,,,2749,1924.3,,,,,,Other,Not Seperately Reimbusable,1869.32,68,,1495.46,Percent of Total Billed Charges,68% of Total Billed Charges,2089.24,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,1374.5,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1374.5,2089.24,
DIAZEPAM 5MG INJ,654075,CDM,636,RC,J3360,HCPCS,Outpatient,5,ME,131,91.7,,6.01,100,,,fee schedule,100% Aetna Market fee schedule,89.08,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,99.56,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,65.5,50,,159.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.5,99.56,
DIAZEPAM 10MG INJ,654200,CDM,636,RC,J3360,HCPCS,Outpatient,10,ME,131,91.7,,6.01,100,,,fee schedule,100% Aetna Market fee schedule,89.08,68,,71.26,Percent of Total Billed Charges,68% of Total Billed Charges,99.56,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,65.5,50,,176.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.5,99.56,
VANCOMYCIN 1GM ADV,654259,CDM,636,RC,J3370,HCPCS,Outpatient,,,39,27.3,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,352,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
VANCOMYCIN 500MG-INJ,654261,CDM,636,RC,J3370,HCPCS,Outpatient,500,ME,58,40.6,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,39.44,68,,31.55,Percent of Total Billed Charges,68% of Total Billed Charges,44.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,29,50,,110,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,44.08,
VANCOMYCIN 1GM INJ,654263,CDM,636,RC,J3370,HCPCS,Outpatient,,,47,32.9,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,79.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.5,35.72,
VANCOMYCIN 1GM PRE,654264,CDM,636,RC,J3370,HCPCS,Outpatient,,,40,28,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,63.84,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,171.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
VANCOYMCIN 750 MG PREMIX INJ,654267,CDM,636,RC,J3370,HCPCS,Outpatient,750,ME,86,60.2,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,58.48,68,,46.78,Percent of Total Billed Charges,68% of Total Billed Charges,65.36,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,43,50,,50,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43,65.36,
VANCOMYCIN 500MG PRE INJ,654268,CDM,636,RC,J3370,HCPCS,Outpatient,500,ME,33,23.1,,2.54,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,65.66,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,148.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,16.5,25.08,
VENOFER 100MG INJ,654600,CDM,636,RC,J1756,HCPCS,Outpatient,100,ME,240,168,,0.24,100,,,fee schedule,100% Aetna Market fee schedule,163.2,68,,130.56,Percent of Total Billed Charges,68% of Total Billed Charges,182.4,76,,752.7,Percent of Total Billed Charges,76% of Total Billed Charges,120,50,,170.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120,182.4,
MIDAZOLAM 2MG-INJ,654809,CDM,636,RC,J2250,HCPCS,Outpatient,2,ME,14,9.8,,0.16,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,182.4,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,94.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
DOXYCYCLINE 100MG INJ,655100,CDM,636,RC,J3490,HCPCS,Outpatient,100,ME,116,81.2,,,,,,Other,Not Seperately Reimbusable,78.88,68,,63.1,Percent of Total Billed Charges,68% of Total Billed Charges,88.16,76,,83.3,Percent of Total Billed Charges,76% of Total Billed Charges,58,50,,67.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58,88.16,
VIMPAT INJ 200MG/20ML,655202,CDM,636,RC,C9254,HCPCS,Outpatient,200,ME,260,182,,0.24,100,,,fee schedule,100% Aetna Market fee schedule,176.8,68,,141.44,Percent of Total Billed Charges,68% of Total Billed Charges,197.6,76,,73.57,Percent of Total Billed Charges,76% of Total Billed Charges,130,50,,102,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,197.6,
HYDROXYZINE 50MG-INJ,655450,CDM,636,RC,J3410,HCPCS,Outpatient,50,ME,107,74.9,,10.9,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,780.67,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,21.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
HALURONIDASE 15UN/ML INJ,656300,CDM,636,RC,J3470,HCPCS,Outpatient,15,ML,268,187.6,,54.24,100,,,fee schedule,100% Aetna Market fee schedule,182.24,68,,145.79,Percent of Total Billed Charges,68% of Total Billed Charges,203.68,76,,232.83,Percent of Total Billed Charges,76% of Total Billed Charges,134,50,,107.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134,203.68,
WYDASE 150 UNIT-INJ,656306,CDM,636,RC,J3470,HCPCS,Outpatient,,,28,19.6,,54.24,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,272.99,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
XOLAIR 150MG INJ,656312,CDM,636,RC,J2357,HCPCS,Outpatient,150,ME,1135,794.5,,43.4,100,,,fee schedule,100% Aetna Market fee schedule,771.8,68,,617.44,Percent of Total Billed Charges,68% of Total Billed Charges,862.6,76,,149.6,Percent of Total Billed Charges,76% of Total Billed Charges,567.5,50,,454,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.29,100,,,Fee Schedule,100% of CMS OPPS Rate,38.29,862.6,
XOPENEX 1.25MG/3ML AEROSOL,656313,CDM,636,RC,J7614,HCPCS,Outpatient,1253,ME,19,13.3,,0.05,100,,,fee schedule,100% Aetna Market fee schedule,12.92,68,,10.34,Percent of Total Billed Charges,68% of Total Billed Charges,14.44,76,,478.72,Percent of Total Billed Charges,76% of Total Billed Charges,9.5,50,,7.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,9.5,14.44,
XYLOCAINE 2% -INJ,656317,CDM,636,RC,J2001,HCPCS,Outpatient,,,14,9.8,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,149.6,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
ALPROSTADIL 500 MCG/ML INJ,656325,CDM,636,RC,J0270,HCPCS,Outpatient,500,ML,334,233.8,,9.78,100,,,fee schedule,100% Aetna Market fee schedule,227.12,68,,181.7,Percent of Total Billed Charges,68% of Total Billed Charges,253.84,76,,262.21,Percent of Total Billed Charges,76% of Total Billed Charges,167,50,,133.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167,253.84,
XYLOCAINE 2% -INJ,656406,CDM,636,RC,J2001,HCPCS,Outpatient,,,107,74.9,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,108.8,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
XYLOCAINE-MPF 4% INJ,656440,CDM,636,RC,J2001,HCPCS,Outpatient,,,49,34.3,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,194.75,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,19.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.5,37.24,
XYLOCAINE C EPI 2% 20MG-INJ,656553,CDM,636,RC,J2001,HCPCS,Outpatient,220,ME,14,9.8,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,9.52,68,,7.62,Percent of Total Billed Charges,68% of Total Billed Charges,10.64,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,7,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7,10.64,
ZANTAC INJ 50MG/2ML,656817,CDM,636,RC,J2780,HCPCS,Outpatient,502,ME,70,49,,6.26,100,,,fee schedule,100% Aetna Market fee schedule,47.6,68,,38.08,Percent of Total Billed Charges,68% of Total Billed Charges,53.2,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,35,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35,53.2,
CEFUROXIME 750MG-INJ,656869,CDM,636,RC,J0697,HCPCS,Outpatient,750,ME,35,24.5,,2.23,100,,,fee schedule,100% Aetna Market fee schedule,23.8,68,,19.04,Percent of Total Billed Charges,68% of Total Billed Charges,26.6,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,17.5,50,,14,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.5,26.6,
CEFUROXIME 1.5GM-INJ,656872,CDM,636,RC,J0697,HCPCS,Outpatient,,,84,58.8,,2.23,100,,,fee schedule,100% Aetna Market fee schedule,57.12,68,,45.7,Percent of Total Billed Charges,68% of Total Billed Charges,63.84,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,42,50,,33.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42,63.84,
ZOSYN 2.25GM ADV-INJ,656972,CDM,636,RC,J2543,HCPCS,Outpatient,,,117,81.9,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,88.92,76,,71.14,Percent of Total Billed Charges,76% of Total Billed Charges,58.5,50,,46.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.5,88.92,
ZOSYN 3.375GM ADV INJ,656973,CDM,636,RC,J2543,HCPCS,Outpatient,,,172,120.4,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,104.58,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,68.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86,130.72,
ZOFRAN 4MG INJ,656976,CDM,636,RC,J2405,HCPCS,Outpatient,4,ME,62,43.4,,0.23,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
ACYCLOVIR 500MG INJ,656982,CDM,636,RC,J0133,HCPCS,Outpatient,500,ME,63,44.1,,0.06,100,,,fee schedule,100% Aetna Market fee schedule,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,38.3,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,25.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
ZOSYN 4.5GM ADV INJ,656992,CDM,636,RC,J2543,HCPCS,Outpatient,,,138,96.6,,1.29,100,,,fee schedule,100% Aetna Market fee schedule,93.84,68,,75.07,Percent of Total Billed Charges,68% of Total Billed Charges,104.88,76,,83.9,Percent of Total Billed Charges,76% of Total Billed Charges,69,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69,104.88,
ZOMETA 4MG INJ,656993,CDM,636,RC,J3489,HCPCS,Outpatient,4,ME,1692,1184.4,,7.93,100,,,fee schedule,100% Aetna Market fee schedule,1150.56,68,,920.45,Percent of Total Billed Charges,68% of Total Billed Charges,1285.92,76,,1028.74,Percent of Total Billed Charges,76% of Total Billed Charges,846,50,,676.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,846,1285.92,
OLANZAPINE 10MG INJ,657072,CDM,636,RC,,,Outpatient,10,ME,110,77,,,,,,Other,Not Seperately Reimbusable,74.8,68,,59.84,Percent of Total Billed Charges,68% of Total Billed Charges,83.6,76,,66.88,Percent of Total Billed Charges,76% of Total Billed Charges,55,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,71.5,65,,57.2,Percent of Total Billed Charges,65% of Total Billed Charges,82.5,75,,66,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,66,60,,52.8,Percent of Total Billed Charges,60% of Total Billed Charges,22.44,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22.44,20.4,,17.95,Percent of Total Billed Charges,20.4% of Total Billed Charges,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,20,,17.6,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,22,83.6,
SUGAMMADEX 500MG INJ,657082,CDM,636,RC,J3490,HCPCS,Outpatient,500,ME,966,676.2,,,,,,Other,Not Seperately Reimbusable,656.88,68,,525.5,Percent of Total Billed Charges,68% of Total Billed Charges,734.16,76,,587.33,Percent of Total Billed Charges,76% of Total Billed Charges,483,50,,386.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,483,734.16,
GENTAMICIN 60 MG IVPB PRE,657086,CDM,636,RC,J1580,HCPCS,Outpatient,60,ME,21,14.7,,2.95,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
ZYVOX 200MG/100ML INJ,657092,CDM,636,RC,J2020,HCPCS,Outpatient,200,ME,303,212.1,,3.63,100,,,fee schedule,100% Aetna Market fee schedule,206.04,68,,164.83,Percent of Total Billed Charges,68% of Total Billed Charges,230.28,76,,184.22,Percent of Total Billed Charges,76% of Total Billed Charges,151.5,50,,121.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.5,230.28,
ZYVOX IV 600MG/300ML,657095,CDM,636,RC,J2020,HCPCS,Outpatient,,,313,219.1,,3.63,100,,,fee schedule,100% Aetna Market fee schedule,212.84,68,,170.27,Percent of Total Billed Charges,68% of Total Billed Charges,237.88,76,,190.3,Percent of Total Billed Charges,76% of Total Billed Charges,156.5,50,,125.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.5,237.88,
OPTISON INJECTION,813080,CDM,636,RC,,,Outpatient,,,294,205.8,,,,,,Other,Not Seperately Reimbusable,199.92,68,,159.94,Percent of Total Billed Charges,68% of Total Billed Charges,223.44,76,,178.75,Percent of Total Billed Charges,76% of Total Billed Charges,147,50,,117.6,Percent of Total Billed Charges,50% of Total Billed Charges,191.1,65,,152.88,Percent of Total Billed Charges,65% of Total Billed Charges,220.5,75,,176.4,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,20,,47.04,Percent of Total Billed Charges,20% of Total Billed Charges,176.4,60,,141.12,Percent of Total Billed Charges,60% of Total Billed Charges,59.98,20.4,,47.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,59.98,20.4,,47.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,58.8,20,,47.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.8,20,,47.04,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,58.8,223.44,
OMNIPAQUE 350 RO 399 PER ML,813090,CDM,636,RC,Q9967,HCPCS,Outpatient,399,ML,16,11.2,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,10.88,68,,8.7,Percent of Total Billed Charges,68% of Total Billed Charges,12.16,76,,9.73,Percent of Total Billed Charges,76% of Total Billed Charges,8,50,,6.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8,12.16,
RX METHYLPREDNISOLONE ACETATE,262300,CDM,636,RC,J1030,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
INJ/RHOGAM INJECTION,308962,CDM,636,RC,J2790,HCPCS,Outpatient,,,316,221.2,,89.28,100,,,fee schedule,100% Aetna Market fee schedule,214.88,68,,171.9,Percent of Total Billed Charges,68% of Total Billed Charges,240.16,76,,192.13,Percent of Total Billed Charges,76% of Total Billed Charges,158,50,,126.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158,240.16,
INJ/ATIVAN 2MG INJ,604977,CDM,636,RC,J2060,HCPCS,Outpatient,2,ME,21,14.7,,1.23,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
INJ/HALDOL 5MG,620400,CDM,636,RC,J1630,HCPCS,Outpatient,5,ME,43,30.1,,1.56,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
INJ/VITAMIN K,624800,CDM,636,RC,J3430,HCPCS,Outpatient,,,21,14.7,,3.19,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
RX HYDROXYZINE HCL 25MG,700000,CDM,636,RC,J3410,HCPCS,Outpatient,25,ME,43,30.1,,10.9,100,,,fee schedule,100% Aetna Market fee schedule,29.24,68,,23.39,Percent of Total Billed Charges,68% of Total Billed Charges,32.68,76,,26.14,Percent of Total Billed Charges,76% of Total Billed Charges,21.5,50,,17.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.5,32.68,
RX PROMETHAZINE HCL 50MG,700400,CDM,636,RC,J2550,HCPCS,Outpatient,50,ME,27,18.9,,3.95,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
RX DEXAMETHASONE SOD PHOSPHT 1,700500,CDM,636,RC,J1100,HCPCS,Outpatient,,,34,23.8,,0.13,100,,,fee schedule,100% Aetna Market fee schedule,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,13.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,25.84,
RX ONDANSETRON HCL PER 1 MG,700600,CDM,636,RC,J2405,HCPCS,Outpatient,1,ME,27,18.9,,0.23,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,10.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
INJ/TETANUS TOXOID,700700,CDM,636,RC,J1670,HCPCS,Outpatient,,,37,25.9,,636.47,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,785.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,581.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,785.4,
RX BUTORPHANOL TARTRATE 1 MG,700800,CDM,636,RC,J0595,HCPCS,Outpatient,1,ME,31,21.7,,3.08,100,,,fee schedule,100% Aetna Market fee schedule,21.08,68,,16.86,Percent of Total Billed Charges,68% of Total Billed Charges,23.56,76,,18.85,Percent of Total Billed Charges,76% of Total Billed Charges,15.5,50,,12.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.5,23.56,
INJ/ANCEF 500MG,701000,CDM,636,RC,J0696,HCPCS,Outpatient,500,ME,34,23.8,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,13.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,25.84,
RX CEFTRIAXONE SODIUM PER 250M,701200,CDM,636,RC,J0696,HCPCS,Outpatient,,,100,70,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,68,68,,54.4,Percent of Total Billed Charges,68% of Total Billed Charges,76,76,,60.8,Percent of Total Billed Charges,76% of Total Billed Charges,50,50,,40,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50,76,
RX KETOROLAC TROMETHAMINE PER,701400,CDM,636,RC,J1885,HCPCS,Outpatient,,,66,46.2,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
RX KETOROLAC TROMETHAMINE PER,701500,CDM,636,RC,J1885,HCPCS,Outpatient,,,34,23.8,,0.54,100,,,fee schedule,100% Aetna Market fee schedule,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,13.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,25.84,
INJ/KENALOG 10MG,701700,CDM,636,RC,J3301,HCPCS,Outpatient,10,ME,28,19.6,,1.04,100,,,fee schedule,100% Aetna Market fee schedule,19.04,68,,15.23,Percent of Total Billed Charges,68% of Total Billed Charges,21.28,76,,17.02,Percent of Total Billed Charges,76% of Total Billed Charges,14,50,,11.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,21.28,
RX NALBUPHINE HCL PER 10MG,702000,CDM,636,RC,J2300,HCPCS,Outpatient,10,ME,60,42,,3.09,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,45.6,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,30,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30,45.6,
RX MEDROXYPROGESTERONE ACETATE,702200,CDM,636,RC,J1050,HCPCS,Outpatient,,,106,74.2,,0.53,100,,,fee schedule,100% Aetna Market fee schedule,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,64.45,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,42.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53,80.56,
INJ/TESTOSTERONE 200MG,702700,CDM,636,RC,J1071,HCPCS,Outpatient,200,ME,85,59.5,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,34,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
RX VITAMIN B12 1000MCG,703000,CDM,636,RC,J3420,HCPCS,Outpatient,,,21,14.7,,1.59,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.5,15.96,
RX AMPICILLIN SODIUM 500MG,703100,CDM,636,RC,J0290,HCPCS,Outpatient,500,ME,22,15.4,,1.11,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
RX AMPICILLIN SODIUM 500MG,703200,CDM,636,RC,J0290,HCPCS,Outpatient,500,ME,44,30.8,,1.11,100,,,fee schedule,100% Aetna Market fee schedule,29.92,68,,23.94,Percent of Total Billed Charges,68% of Total Billed Charges,33.44,76,,26.75,Percent of Total Billed Charges,76% of Total Billed Charges,22,50,,17.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22,33.44,
"RX BUPRENORPHINE IMPLANT, 74.2",703300,CDM,636,RC,J0570,HCPCS,Outpatient,,,47,32.9,,1202.85,100,,,fee schedule,100% Aetna Market fee schedule,31.96,68,,25.57,Percent of Total Billed Charges,68% of Total Billed Charges,35.72,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,23.5,50,,18.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1770.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1311.75,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1311.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1311.75,100,,,Fee Schedule,100% of CMS OPPS Rate,23.5,1770.86,
RX PENICILLIN G BENZ 100000 UN,703400,CDM,636,RC,J0561,HCPCS,Outpatient,,,832,582.4,,23.9,100,,,fee schedule,100% Aetna Market fee schedule,565.76,68,,452.61,Percent of Total Billed Charges,68% of Total Billed Charges,632.32,76,,505.86,Percent of Total Billed Charges,76% of Total Billed Charges,416,50,,332.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24.37,632.32,
INJ/BICILLIN 100000,703500,CDM,636,RC,J0561,HCPCS,Outpatient,,,21,14.7,,23.9,100,,,fee schedule,100% Aetna Market fee schedule,14.28,68,,11.42,Percent of Total Billed Charges,68% of Total Billed Charges,15.96,76,,12.77,Percent of Total Billed Charges,76% of Total Billed Charges,10.5,50,,8.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,32.89,
INJ/EPINIPHRINE,704100,CDM,636,RC,J0170,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
INJ/BICILN CR 300000,704500,CDM,636,RC,J0560,HCPCS,Outpatient,,,13,9.1,,,,,,Other,Not Seperately Reimbusable,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,9.88,
RX METHYLPREDNISOLONE ACETATE,706400,CDM,636,RC,J1010,HCPCS,Outpatient,,,26,18.2,,,,,,Other,Not Seperately Reimbusable,17.68,68,,14.14,Percent of Total Billed Charges,68% of Total Billed Charges,19.76,76,,15.81,Percent of Total Billed Charges,76% of Total Billed Charges,13,50,,10.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13,19.76,
RX DIPHENHYDRAMINE HCL 50MG,706800,CDM,636,RC,J1200,HCPCS,Outpatient,50,ME,34,23.8,,0.88,100,,,fee schedule,100% Aetna Market fee schedule,23.12,68,,18.5,Percent of Total Billed Charges,68% of Total Billed Charges,25.84,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,17,50,,13.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17,25.84,
RX MEPERIDINE HCL PER 100MG,707300,CDM,636,RC,J2175,HCPCS,Outpatient,100,ME,22,15.4,,8.03,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
RX DEPO-ESTRADIOL CYPIONATE 5M,707500,CDM,636,RC,J1000,HCPCS,Outpatient,,,22,15.4,,39.33,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
RX ESTRADIOL VALERATE 10MG,707700,CDM,636,RC,J1380,HCPCS,Outpatient,10,ME,22,15.4,,10.16,100,,,fee schedule,100% Aetna Market fee schedule,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,16.72,
RX LINCOMYCIN HCL 300MG,707800,CDM,636,RC,J2010,HCPCS,Outpatient,300,ME,66,46.2,,10.83,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
RX MORPHINE SULFATE 10MG,708300,CDM,636,RC,J2270,HCPCS,Outpatient,10,ME,24,16.8,,5.13,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
RX ORPHENADRINE CITRATE UP TO,708400,CDM,636,RC,J2360,HCPCS,Outpatient,,,41,28.7,,10.68,100,,,fee schedule,100% Aetna Market fee schedule,27.88,68,,22.3,Percent of Total Billed Charges,68% of Total Billed Charges,31.16,76,,24.93,Percent of Total Billed Charges,76% of Total Billed Charges,20.5,50,,16.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.5,31.16,
RX METHYLPREDNISOLONE ACETATE,708900,CDM,636,RC,J1040,HCPCS,Outpatient,,,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
RX TESTOSTERONE CYPIONATE 1MG,709400,CDM,636,RC,J1071,HCPCS,Outpatient,1,ME,85,59.5,,0.03,100,,,fee schedule,100% Aetna Market fee schedule,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,51.68,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,34,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
INJ/INFED,709800,CDM,636,RC,J1751,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,32.64,68,,26.11,Percent of Total Billed Charges,68% of Total Billed Charges,36.48,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,24,50,,19.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24,36.48,
RX INSULIN PER 5 UNITS,709900,CDM,636,RC,J1815,HCPCS,Outpatient,,,8,5.6,,0.3,100,,,fee schedule,100% Aetna Market fee schedule,5.44,68,,4.35,Percent of Total Billed Charges,68% of Total Billed Charges,6.08,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,4,50,,3.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,6.08,
RX PROCHLORPERAZINE 10MG/2ML I,710000,CDM,636,RC,J0780,HCPCS,Outpatient,102,ME,103,72.1,,3.77,100,,,fee schedule,100% Aetna Market fee schedule,70.04,68,,56.03,Percent of Total Billed Charges,68% of Total Billed Charges,78.28,76,,62.62,Percent of Total Billed Charges,76% of Total Billed Charges,51.5,50,,41.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.5,78.28,
RX METHYLPREDNISOLO 40MG VIAL,710100,CDM,636,RC,J2920,HCPCS,Outpatient,40,ME,39,27.3,,,,,,Other,Not Seperately Reimbusable,26.52,68,,21.22,Percent of Total Billed Charges,68% of Total Billed Charges,29.64,76,,23.71,Percent of Total Billed Charges,76% of Total Billed Charges,19.5,50,,15.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.5,29.64,
RX PHYTONADIONE (VITAMIN K) PE,712400,CDM,636,RC,J3430,HCPCS,Outpatient,,,24,16.8,,3.19,100,,,fee schedule,100% Aetna Market fee schedule,16.32,68,,13.06,Percent of Total Billed Charges,68% of Total Billed Charges,18.24,76,,14.59,Percent of Total Billed Charges,76% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12,18.24,
INJ/VALIUM 10MG,712600,CDM,636,RC,J3360,HCPCS,Outpatient,10,ME,17,11.9,,6.01,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,10.34,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,6.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.5,12.92,
IMM/RABIES VACCINE,715000,CDM,636,RC,90675,HCPCS,Outpatient,,,162,113.4,,324.74,100,,,fee schedule,100% Aetna Market fee schedule,110.16,68,,88.13,Percent of Total Billed Charges,68% of Total Billed Charges,123.12,76,,98.5,Percent of Total Billed Charges,76% of Total Billed Charges,81,50,,64.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,81,472.68,
INJ/DEPO MEDROL 20MG,715100,CDM,636,RC,J1020,HCPCS,Outpatient,20,ME,9,6.3,,,,,,Other,Not Seperately Reimbusable,6.12,68,,4.9,Percent of Total Billed Charges,68% of Total Billed Charges,6.84,76,,5.47,Percent of Total Billed Charges,76% of Total Billed Charges,4.5,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.5,6.84,
RX METHYLPREDNISOLONE 5 MG,722000,CDM,636,RC,J2919,HCPCS,Outpatient,5,ME,50,35,,,,,,Other,Not Seperately Reimbusable,34,68,,27.2,Percent of Total Billed Charges,68% of Total Billed Charges,38,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,25,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25,38,
RX CLINDAMYCIN 300 MG INJ,723000,CDM,636,RC,J0736,HCPCS,Outpatient,300,ME,33,23.1,,2.09,100,,,fee schedule,100% Aetna Market fee schedule,22.44,68,,17.95,Percent of Total Billed Charges,68% of Total Billed Charges,25.08,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,16.5,50,,13.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2.47,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,25.08,
INJ/MITOMYCIN 20MG,7051000,CDM,636,RC,J9291,HCPCS,Outpatient,20,ME,508,355.6,,,,,,Other,Not Seperately Reimbusable,345.44,68,,276.35,Percent of Total Billed Charges,68% of Total Billed Charges,386.08,76,,308.86,Percent of Total Billed Charges,76% of Total Billed Charges,254,50,,203.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254,386.08,
RX TETANUS IMMUNE GLUBULIN TIG,9038900,CDM,636,RC,90389,HCPCS,Outpatient,,,37,25.9,,642.86,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
RX HUMAN PAPILLOMA VACCINE,9064900,CDM,636,RC,90649,HCPCS,Outpatient,,,311,217.7,,163.24,100,,,fee schedule,100% Aetna Market fee schedule,211.48,68,,169.18,Percent of Total Billed Charges,68% of Total Billed Charges,236.36,76,,189.09,Percent of Total Billed Charges,76% of Total Billed Charges,155.5,50,,124.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.5,236.36,
IMM/INFLU VAC-SPLIT 6-35 MTHS,9065700,CDM,636,RC,90657,HCPCS,Outpatient,,,36,25.2,,9.5,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.86,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,27.36,
IMM/INFLU VAC-SPLIT 3YRS AND A,9065800,CDM,636,RC,90658,HCPCS,Outpatient,,,36,25.2,,16.32,100,,,fee schedule,100% Aetna Market fee schedule,24.48,68,,19.58,Percent of Total Billed Charges,68% of Total Billed Charges,27.36,76,,21.89,Percent of Total Billed Charges,76% of Total Billed Charges,18,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.72,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18,43.72,
RX FLU PRESERV FREE INCR ANTIG,9066200,CDM,636,RC,90662,HCPCS,Outpatient,,,62,43.4,,73.4,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,Percent of Total Billed Charges,50% of Total Billed Charges,166.98,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,166.98,
RX PNEUMO CONJ PCV13 IM,9067000,CDM,636,RC,90670,HCPCS,Outpatient,,,223,156.1,,257.99,100,,,fee schedule,100% Aetna Market fee schedule,151.64,68,,121.31,Percent of Total Billed Charges,68% of Total Billed Charges,169.48,76,,135.58,Percent of Total Billed Charges,76% of Total Billed Charges,111.5,50,,89.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.5,169.48,
IMM/FLUBLOK 18 YRS AND OLDER 0,9068200,CDM,636,RC,90682,HCPCS,Outpatient,,,62,43.4,,73.4,100,,,fee schedule,100% Aetna Market fee schedule,42.16,68,,33.73,Percent of Total Billed Charges,68% of Total Billed Charges,47.12,76,,37.7,Percent of Total Billed Charges,76% of Total Billed Charges,31,50,,24.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,47.12,
IMM/FLUZONE 6 THRU 35 MO 0.25M,9068500,CDM,636,RC,,,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,14.96,68,,11.97,Percent of Total Billed Charges,68% of Total Billed Charges,16.72,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,11,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,14.3,65,,11.44,Percent of Total Billed Charges,65% of Total Billed Charges,16.5,75,,13.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,13.2,60,,10.56,Percent of Total Billed Charges,60% of Total Billed Charges,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.49,20.4,,3.59,Percent of Total Billed Charges,20.4% of Total Billed Charges,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4.4,20,,3.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,4.4,16.72,
IMM/FLUZONE 3YRS & UP 5.0ML MU,9068800,CDM,636,RC,90688,HCPCS,Outpatient,350,ML,20,14,,20.88,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10,15.2,
RX DTAP VACCINE YOUNGER THAN 7,9070000,CDM,636,RC,90700,HCPCS,Outpatient,,,66,46.2,,29.53,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
RX DT ADSORBED PEDI USE IM,9070200,CDM,636,RC,90702,HCPCS,Outpatient,,,37,25.9,,67.16,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,28.12,
RX VACCINE MMR LIVE,9070700,CDM,636,RC,90707,HCPCS,Outpatient,,,107,74.9,,94.5,100,,,fee schedule,100% Aetna Market fee schedule,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
RX TETANUS DIPTH PERT (TDAP) A,9071500,CDM,636,RC,90715,HCPCS,Outpatient,,,144,100.8,,38.31,100,,,fee schedule,100% Aetna Market fee schedule,97.92,68,,78.34,Percent of Total Billed Charges,68% of Total Billed Charges,109.44,76,,87.55,Percent of Total Billed Charges,76% of Total Billed Charges,72,50,,57.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,109.44,
IMM/DIPHTHERIA TOXOID,9071900,CDM,636,RC,90719,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33,50.16,
"IMM/DIPHTHERIA,TETANUS,PERTUSS",9072000,CDM,636,RC,90720,HCPCS,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,59.28,
"IMM/DIP,TET,ACE PER HIB (DTAP-",9072100,CDM,636,RC,90721,HCPCS,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,59.28,
IMM/DTAP-HEP B-IPV,9072300,CDM,636,RC,90723,HCPCS,Outpatient,,,78,54.6,,95.5,100,,,fee schedule,100% Aetna Market fee schedule,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,59.28,
RX PNEUMOCOCCAL POLY VAC,9073200,CDM,636,RC,90732,HCPCS,Outpatient,,,144,100.8,,133.47,100,,,fee schedule,100% Aetna Market fee schedule,97.92,68,,78.34,Percent of Total Billed Charges,68% of Total Billed Charges,109.44,76,,87.55,Percent of Total Billed Charges,76% of Total Billed Charges,72,50,,57.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72,109.44,
IMM/MENINGOCOCCAL POLYSACCHARI,9073300,CDM,636,RC,90733,HCPCS,Outpatient,,,96,67.2,,125.5,100,,,fee schedule,100% Aetna Market fee schedule,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,58.37,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,38.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
IMM/HEP B VACCINE ADULT DOSAGE,9074600,CDM,636,RC,90746,HCPCS,Outpatient,,,78,54.6,,70.38,100,,,fee schedule,100% Aetna Market fee schedule,53.04,68,,42.43,Percent of Total Billed Charges,68% of Total Billed Charges,59.28,76,,47.42,Percent of Total Billed Charges,76% of Total Billed Charges,39,50,,31.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39,59.28,
INJ/BOTULINUM TOXIN,9939701,CDM,636,RC,J0585,HCPCS,Outpatient,,,871,609.7,,6.96,100,,,fee schedule,100% Aetna Market fee schedule,592.28,68,,473.82,Percent of Total Billed Charges,68% of Total Billed Charges,661.96,76,,529.57,Percent of Total Billed Charges,76% of Total Billed Charges,435.5,50,,348.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,661.96,
RX RABIES VACCINE IM,9949001,CDM,636,RC,90675,HCPCS,Outpatient,,,66,46.2,,324.74,100,,,fee schedule,100% Aetna Market fee schedule,44.88,68,,35.9,Percent of Total Billed Charges,68% of Total Billed Charges,50.16,76,,40.13,Percent of Total Billed Charges,76% of Total Billed Charges,33,50,,26.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,472.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.14,100,,,Fee Schedule,100% of CMS OPPS Rate,33,472.68,
ECG TRACING ONLY W/O INTER,323380,CDM,730,RC,93005,HCPCS,Outpatient,,,287,200.9,,5.48,100,,,fee schedule,100% Aetna Market fee schedule,195.16,68,,156.13,Percent of Total Billed Charges,68% of Total Billed Charges,218.12,76,,337.82,Percent of Total Billed Charges,76% of Total Billed Charges,143.5,50,,33.6,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,218.12,
ECG TRACING ONLY W/O INTER,201427,CDM,730,RC,93005,HCPCS,Outpatient,,,287,200.9,,5.48,100,,,fee schedule,100% Aetna Market fee schedule,195.16,68,,156.13,Percent of Total Billed Charges,68% of Total Billed Charges,218.12,76,,137.09,Percent of Total Billed Charges,76% of Total Billed Charges,143.5,50,,22.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,218.12,
RHYTHM ECG TRACE WO INTER,201430,CDM,730,RC,93041,HCPCS,Outpatient,,,168,117.6,,5.17,100,,,fee schedule,100% Aetna Market fee schedule,114.24,68,,91.39,Percent of Total Billed Charges,68% of Total Billed Charges,127.68,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,84,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,127.68,
EKG W/O  INTERPRETATION & REPO,323390,CDM,730,RC,93005,HCPCS,Outpatient,,,287,200.9,,5.48,100,,,fee schedule,100% Aetna Market fee schedule,195.16,68,,156.13,Percent of Total Billed Charges,68% of Total Billed Charges,218.12,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,143.5,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,218.12,
ELECTROCARDIOGRAM,323400,CDM,730,RC,93005,HCPCS,Outpatient,,,287,200.9,,5.48,100,,,fee schedule,100% Aetna Market fee schedule,195.16,68,,156.13,Percent of Total Billed Charges,68% of Total Billed Charges,218.12,76,,174.5,Percent of Total Billed Charges,76% of Total Billed Charges,143.5,50,,114.8,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,218.12,
EKG - ER/PHONE GRAM,323517,CDM,730,RC,93012,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
ECG TRACING ONLY W/O INTER,9300500,CDM,730,RC,93005,HCPCS,Outpatient,,,20,14,,5.48,100,,,fee schedule,100% Aetna Market fee schedule,13.6,68,,10.88,Percent of Total Billed Charges,68% of Total Billed Charges,15.2,76,,12.16,Percent of Total Billed Charges,76% of Total Billed Charges,10,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,10.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10,74.68,
EXT ECG>48HRS<7D RECORDING,840496,CDM,731,RC,93242,HCPCS,Outpatient,,,102,71.4,,12.82,100,,,fee schedule,100% Aetna Market fee schedule,69.36,68,,55.49,Percent of Total Billed Charges,68% of Total Billed Charges,77.52,76,,46.21,Percent of Total Billed Charges,76% of Total Billed Charges,51,50,,5.6,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,33.3,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,33.3,102,,,Fee Schedule,102% of MO Medicaid rate,32.65,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,20.66,77.52,
EXT ECG>7D<15D RECORDING,850490,CDM,731,RC,93246,HCPCS,Outpatient,,,172,120.4,,12.82,100,,,fee schedule,100% Aetna Market fee schedule,116.96,68,,93.57,Percent of Total Billed Charges,68% of Total Billed Charges,130.72,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,86,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,33.3,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,33.3,102,,,Fee Schedule,102% of MO Medicaid rate,32.65,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,20.66,130.72,
ECG MONITOR UP TO 48 HRS REC H,850491,CDM,731,RC,93225,HCPCS,Outpatient,,,348,243.6,,17.42,100,,,fee schedule,100% Aetna Market fee schedule,236.64,68,,189.31,Percent of Total Billed Charges,68% of Total Billed Charges,264.48,76,,21.28,Percent of Total Billed Charges,76% of Total Billed Charges,174,50,,8.8,Percent of Total Billed Charges,50% of Total Billed Charges,31.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,31.52,264.48,
ECG MONITOR UP TO 48 HRS SCAN,850492,CDM,731,RC,93226,HCPCS,Outpatient,,,348,243.6,,34.25,100,,,fee schedule,100% Aetna Market fee schedule,236.64,68,,189.31,Percent of Total Billed Charges,68% of Total Billed Charges,264.48,76,,16.42,Percent of Total Billed Charges,76% of Total Billed Charges,174,50,,25.6,Percent of Total Billed Charges,50% of Total Billed Charges,61.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,49.79,264.48,
HOLTER ANALYSIS,850447,CDM,731,RC,93226,HCPCS,Outpatient,,,267,186.9,,34.25,100,,,fee schedule,100% Aetna Market fee schedule,181.56,68,,145.25,Percent of Total Billed Charges,68% of Total Billed Charges,202.92,76,,162.34,Percent of Total Billed Charges,76% of Total Billed Charges,133.5,50,,106.8,Percent of Total Billed Charges,50% of Total Billed Charges,61.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,49.79,202.92,
HOLTER MONITOR-24 HR,850449,CDM,731,RC,93225,HCPCS,Outpatient,,,60,42,,17.42,100,,,fee schedule,100% Aetna Market fee schedule,40.8,68,,32.64,Percent of Total Billed Charges,68% of Total Billed Charges,45.6,76,,36.48,Percent of Total Billed Charges,76% of Total Billed Charges,30,50,,24,Percent of Total Billed Charges,50% of Total Billed Charges,31.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,30,155.96,
HOLTER MONITOR 3-14 DAYS,850470,CDM,731,RC,93246,HCPCS,Outpatient,,,40,28,,12.82,100,,,fee schedule,100% Aetna Market fee schedule,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,16,Percent of Total Billed Charges,50% of Total Billed Charges,20.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,48.96,135,,,Fee Schedule,135% of CMS OPPS Rate,33.3,102,,,Fee Schedule,102% MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS rate,33.3,102,,,Fee Schedule,102% of MO Medicaid rate,32.65,100,,,Fee Schedule,100% of MO Medicaid rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,32.65,100,,,Fee Schedule,100% of MO Medicaid Rate,36.27,100,,,Fee Schedule,100% of CMS OPPS Rate,20,75,
CARDIAC MONITORING,852312,CDM,731,RC,93226,HCPCS,Outpatient,,,201,140.7,,34.25,100,,,fee schedule,100% Aetna Market fee schedule,136.68,68,,109.34,Percent of Total Billed Charges,68% of Total Billed Charges,152.76,76,,122.21,Percent of Total Billed Charges,76% of Total Billed Charges,100.5,50,,80.4,Percent of Total Billed Charges,50% of Total Billed Charges,61.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,50.79,102,,,Fee Schedule,102% MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,50.79,102,,,Fee Schedule,102% of MO Medicaid rate,49.79,100,,,Fee Schedule,100% of MO Medicaid rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,49.79,100,,,Fee Schedule,100% of MO Medicaid Rate,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,49.79,152.76,
RHYTHM STRIP,323500,CDM,732,RC,93012,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,72.76,68,,58.21,Percent of Total Billed Charges,68% of Total Billed Charges,81.32,76,,65.06,Percent of Total Billed Charges,76% of Total Billed Charges,53.5,50,,42.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.5,81.32,
TELEMETRY ECG MONITORING UP TO,852322,CDM,732,RC,93229,HCPCS,Outpatient,,,428,299.6,,806.19,100,,,fee schedule,100% Aetna Market fee schedule,291.04,68,,232.83,Percent of Total Billed Charges,68% of Total Billed Charges,325.28,76,,260.22,Percent of Total Billed Charges,76% of Total Billed Charges,214,50,,171.2,Percent of Total Billed Charges,50% of Total Billed Charges,856,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,75,856,
TELEMETRY ECG MONITORING UP TO,893594,CDM,732,RC,93228,HCPCS,Outpatient,,,345,241.5,,23.59,100,,,fee schedule,100% Aetna Market fee schedule,234.6,68,,187.68,Percent of Total Billed Charges,68% of Total Billed Charges,262.2,76,,209.76,Percent of Total Billed Charges,76% of Total Billed Charges,172.5,50,,138,Percent of Total Billed Charges,50% of Total Billed Charges,47.04,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.04,262.2,
EEG-RESPIRATORY DEPT,327100,CDM,740,RC,93012,HCPCS,Outpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,
ELECTROENCEPHALOGRAM,327350,CDM,740,RC,95819,HCPCS,Outpatient,,,1500,1050,,52.67,100,,,fee schedule,100% Aetna Market fee schedule,1020,68,,816,Percent of Total Billed Charges,68% of Total Billed Charges,1140,76,,912,Percent of Total Billed Charges,76% of Total Billed Charges,750,50,,600,Percent of Total Billed Charges,50% of Total Billed Charges,685.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,1140,
EEG MONITORING;41-60 MIN,327351,CDM,740,RC,95812,HCPCS,Outpatient,,,400,280,,52.36,100,,,fee schedule,100% Aetna Market fee schedule,272,68,,217.6,Percent of Total Billed Charges,68% of Total Billed Charges,304,76,,243.2,Percent of Total Billed Charges,76% of Total Billed Charges,200,50,,160,Percent of Total Billed Charges,50% of Total Billed Charges,506.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,506.4,
EEG MONITORING;GREATER THAN 1,327352,CDM,740,RC,95813,HCPCS,Outpatient,,,439,307.3,,79.73,100,,,fee schedule,100% Aetna Market fee schedule,298.52,68,,238.82,Percent of Total Billed Charges,68% of Total Billed Charges,333.64,76,,266.91,Percent of Total Billed Charges,76% of Total Billed Charges,219.5,50,,175.6,Percent of Total Billed Charges,50% of Total Billed Charges,616.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.88,100,,,Fee Schedule,100% of CMS OPPS Rate,100,616.86,
EGD REMV TUM FORC HOT BX,540911,CDM,750,RC,43250,HCPCS,Outpatient,,,3114,2179.8,,154.16,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,1557,50,,80.8,Percent of Total Billed Charges,50% of Total Billed Charges,318.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,318.82,2323.29,
EGD CONTROL BLEEDING,540912,CDM,750,RC,43255,HCPCS,Outpatient,,,3114,2179.8,,182.09,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,1557,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,373.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,373.96,2323.29,
SIGMOID FLEX DIAGNOSTIC,540913,CDM,750,RC,45330,HCPCS,Outpatient,,,1528,1069.6,,50.64,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,764,50,,40.8,Percent of Total Billed Charges,50% of Total Billed Charges,105.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,105.44,1115.91,
SIGMOID FLEX REM TUM FORCEP,540914,CDM,750,RC,45333,HCPCS,Outpatient,,,1528,1069.6,,85.02,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,764,50,,14,Percent of Total Billed Charges,50% of Total Billed Charges,176.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1115.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,366,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,826.6,100,,,Fee Schedule,100% of CMS OPPS Rate,176.5,1115.91,
SIGMOID FLEX REM TUM SNARE,540915,CDM,750,RC,45338,HCPCS,Outpatient,,,2008,1405.6,,109.03,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,1004,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,224.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,224.82,1440.83,
COLONOSCOPY LESN REMOV SNARE,540916,CDM,750,RC,45385,HCPCS,Outpatient,,,2008,1405.6,,231.08,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,334.4,Percent of Total Billed Charges,76% of Total Billed Charges,1004,50,,4,Percent of Total Billed Charges,50% of Total Billed Charges,475.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1440.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1067.27,100,,,Fee Schedule,100% of CMS OPPS Rate,475.52,1440.83,
EGD REMOVE TUM SNARE,541006,CDM,750,RC,43251,HCPCS,Outpatient,,,3114,2179.8,,177.71,100,,,fee schedule,100% Aetna Market fee schedule,601.32,68,,481.06,Percent of Total Billed Charges,68% of Total Billed Charges,644.72,76,,515.78,Percent of Total Billed Charges,76% of Total Billed Charges,1557,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,366.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2323.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,492,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,1720.96,100,,,Fee Schedule,100% of CMS OPPS Rate,366.32,2323.29,
CLINIC NEW LEVEL 1 PROBLEM FOC,201133,CDM,761,RC,X4003,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,51,68,,40.8,Percent of Total Billed Charges,68% of Total Billed Charges,57,76,,17.41,Percent of Total Billed Charges,76% of Total Billed Charges,37.5,50,,40.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.5,57,
CLINIC NEW LEVEL 2 EXPANDED LO,201136,CDM,761,RC,X4003,HCPCS,Outpatient,,,96,67.2,,,,,,Other,Not Seperately Reimbusable,65.28,68,,52.22,Percent of Total Billed Charges,68% of Total Billed Charges,72.96,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,48,50,,278.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48,72.96,
CLINIC NEW LEVEL 3 EXPANDED MO,201139,CDM,761,RC,X4003,HCPCS,Outpatient,,,117,81.9,,,,,,Other,Not Seperately Reimbusable,79.56,68,,63.65,Percent of Total Billed Charges,68% of Total Billed Charges,88.92,76,,17.41,Percent of Total Billed Charges,76% of Total Billed Charges,58.5,50,,230.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.5,88.92,
CLINIC NEW LEVEL 4 DETAILED,201142,CDM,761,RC,X4003,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,93.16,68,,74.53,Percent of Total Billed Charges,68% of Total Billed Charges,104.12,76,,17.41,Percent of Total Billed Charges,76% of Total Billed Charges,68.5,50,,155.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.5,104.12,
CLINIC NEW LEVEL 5 COMPREHENSI,201145,CDM,761,RC,X4003,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,108.12,68,,86.5,Percent of Total Billed Charges,68% of Total Billed Charges,120.84,76,,2.72,Percent of Total Billed Charges,76% of Total Billed Charges,79.5,50,,87.2,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.5,120.84,
CLINIC EST LEVEL 1 PROBLEM FOC,201157,CDM,761,RC,X4003,HCPCS,Outpatient,,,63,44.1,,,,,,Other,Not Seperately Reimbusable,42.84,68,,34.27,Percent of Total Billed Charges,68% of Total Billed Charges,47.88,76,,17.95,Percent of Total Billed Charges,76% of Total Billed Charges,31.5,50,,596.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.5,47.88,
CLINIC EST LEVEL 2 EXPANDED LO,201160,CDM,761,RC,X4003,HCPCS,Outpatient,,,85,59.5,,,,,,Other,Not Seperately Reimbusable,57.8,68,,46.24,Percent of Total Billed Charges,68% of Total Billed Charges,64.6,76,,15.23,Percent of Total Billed Charges,76% of Total Billed Charges,42.5,50,,183.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.5,64.6,
CLINIC EST LEVEL 3 EXPANDED MO,201163,CDM,761,RC,X4003,HCPCS,Outpatient,,,106,74.2,,,,,,Other,Not Seperately Reimbusable,72.08,68,,57.66,Percent of Total Billed Charges,68% of Total Billed Charges,80.56,76,,20.67,Percent of Total Billed Charges,76% of Total Billed Charges,53,50,,116.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53,80.56,
CLINIC EST LEVEL 4 DETAILED,201166,CDM,761,RC,X4003,HCPCS,Outpatient,,,128,89.6,,,,,,Other,Not Seperately Reimbusable,87.04,68,,69.63,Percent of Total Billed Charges,68% of Total Billed Charges,97.28,76,,39.17,Percent of Total Billed Charges,76% of Total Billed Charges,64,50,,260.4,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64,97.28,
CLINIC EST LEVEL 5 COMPREHENSI,201169,CDM,761,RC,X4003,HCPCS,Outpatient,,,148,103.6,,,,,,Other,Not Seperately Reimbusable,100.64,68,,80.51,Percent of Total Billed Charges,68% of Total Billed Charges,112.48,76,,2.72,Percent of Total Billed Charges,76% of Total Billed Charges,74,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74,112.48,
THERAPEUTIC INJ IV PUSH ADMIN,5829,CDM,761,RC,90774,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,17,68,,13.6,Percent of Total Billed Charges,68% of Total Billed Charges,19,76,,28.58,Percent of Total Billed Charges,76% of Total Billed Charges,12.5,50,,14.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,12.5,19,
ALLERGY TESTING PERCUT.,5900,CDM,761,RC,95004,HCPCS,Outpatient,,,11,7.7,,3.66,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,1.82,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,16.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1276.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,945.61,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,945.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,945.61,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,1276.57,
ANTIGEN THERAPY SERVICES,5901,CDM,761,RC,95165,HCPCS,Outpatient,,,17,11.9,,2.82,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,348.38,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,10.4,Percent of Total Billed Charges,50% of Total Billed Charges,6.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,6.34,57.99,
IMMUNO ONE INJ,5902,CDM,761,RC,95115,HCPCS,Outpatient,,,11,7.7,,8.54,100,,,fee schedule,100% Aetna Market fee schedule,7.48,68,,5.98,Percent of Total Billed Charges,68% of Total Billed Charges,8.36,76,,249.28,Percent of Total Billed Charges,76% of Total Billed Charges,5.5,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,17.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,57.99,
IMMUNO INJS,5903,CDM,761,RC,95117,HCPCS,Outpatient,,,17,11.9,,10.38,100,,,fee schedule,100% Aetna Market fee schedule,11.56,68,,9.25,Percent of Total Billed Charges,68% of Total Billed Charges,12.92,76,,252.93,Percent of Total Billed Charges,76% of Total Billed Charges,8.5,50,,4.4,Percent of Total Billed Charges,50% of Total Billed Charges,21.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,8.5,57.99,
DEBRIDE DEVITALIZED TISSUE,9002,CDM,761,RC,97597,HCPCS,Outpatient,,,275,192.5,,33.45,100,,,fee schedule,100% Aetna Market fee schedule,187,68,,149.6,Percent of Total Billed Charges,68% of Total Billed Charges,209,76,,0.61,Percent of Total Billed Charges,76% of Total Billed Charges,137.5,50,,137.6,Percent of Total Billed Charges,50% of Total Billed Charges,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,67.72,244.43,
ACTIVE WOUND MANAGEMENT,9010,CDM,761,RC,97602,HCPCS,Outpatient,,,138,96.6,,82.4,100,,,fee schedule,100% Aetna Market fee schedule,93.84,68,,75.07,Percent of Total Billed Charges,68% of Total Billed Charges,104.88,76,,29.18,Percent of Total Billed Charges,76% of Total Billed Charges,69,50,,3.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.06,100,,,Fee Schedule,100% of CMS OPPS Rate,69,244.44,
OBSERVATION-DIRECT,201255,CDM,762,RC,,,Outpatient,,,1576,1103.2,,,,,,Other,Not Seperately Reimbusable,1071.68,68,,857.34,Percent of Total Billed Charges,68% of Total Billed Charges,1071.68,68,,2.72,Percent of Total Billed Charges,68% of Total Billed Charges,788,50,,52.8,Percent of Total Billed Charges,50% of Total Billed Charges,1024.4,65,,819.52,Percent of Total Billed Charges,65% of Total Billed Charges,1182,75,,945.6,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1100,70,,880,Percent of Total Billed Charges,70% of Total Billed Charges,1182,75,,945.6,Percent of Total Billed Charges,75% of Total Billed Charges,315.2,20,,252.16,Percent of Total Billed Charges,20% of Total Billed Charges,945.6,60,,756.48,Percent of Total Billed Charges,60% of Total Billed Charges,321.5,20.4,,257.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,321.5,20.4,,257.2,Percent of Total Billed Charges,20.4% of Total Billed Charges,315.2,20,,252.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,1000,100,,,Case Rate,Pays based on per visit rate,315.2,20,,252.16,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,315.2,1182,
OBS CARE BY FAC EA HR,201260,CDM,762,RC,G0378,HCPCS,Outpatient,,,37,25.9,,60.88,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,141.44,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,46.4,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,70,,20.72,Percent of Total Billed Charges,70% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1000,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,1000,
OBS CARE BY FAC EA HR-MED SURG,790020,CDM,762,RC,G0378,HCPCS,Outpatient,,,37,25.9,,60.88,100,,,fee schedule,100% Aetna Market fee schedule,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,18.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.9,70,,20.72,Percent of Total Billed Charges,70% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1000,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.5,1000,
DIRECT ADMIT TO OBS-MED SURG,790030,CDM,762,RC,G0379,HCPCS,Outpatient,,,1513,1059.1,,44.59,100,,,fee schedule,100% Aetna Market fee schedule,1028.84,68,,823.07,Percent of Total Billed Charges,68% of Total Billed Charges,1028.84,68,,823.07,Percent of Total Billed Charges,68% of Total Billed Charges,756.5,50,,605.2,Percent of Total Billed Charges,50% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1059.1,70,,847.28,Percent of Total Billed Charges,70% of Total Billed Charges,1134.75,75,,907.8,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,784.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1000,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,580.91,100,,,Fee Schedule,100% of CMS OPPS Rate,580.91,1134.75,
ADMIN IMMUN INITIAL VACCINE,201190,CDM,771,RC,90471,HCPCS,Outpatient,,,202,141.4,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,137.36,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,153.52,76,,7.62,Percent of Total Billed Charges,76% of Total Billed Charges,101,50,,7.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.12,153.52,
ADMIN IMMUN EA ADD VACC,201191,CDM,771,RC,90472,HCPCS,Outpatient,,,210,147,,12.13,100,,,fee schedule,100% Aetna Market fee schedule,142.8,68,,114.24,Percent of Total Billed Charges,68% of Total Billed Charges,159.6,76,,86.5,Percent of Total Billed Charges,76% of Total Billed Charges,105,50,,44,Percent of Total Billed Charges,50% of Total Billed Charges,26.64,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,26.64,159.6,
SOTROVIMAB INFSN W POST ADMN M,5727,CDM,771,RC,M0247,HCPCS,Outpatient,,,1352,946.4,,450,100,,,fee schedule,100% Aetna Market fee schedule,919.36,68,,735.49,Percent of Total Billed Charges,68% of Total Billed Charges,1027.52,76,,9.25,Percent of Total Billed Charges,76% of Total Billed Charges,676,50,,28.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,577.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,427.63,1027.52,
BAMLAN AND ETESEV INFUSION,5726,CDM,771,RC,M0245,HCPCS,Outpatient,,,1350,945,,450,100,,,fee schedule,100% Aetna Market fee schedule,918,68,,734.4,Percent of Total Billed Charges,68% of Total Billed Charges,1026,76,,231.04,Percent of Total Billed Charges,76% of Total Billed Charges,675,50,,1.6,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,577.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.63,100,,,Fee Schedule,100% of CMS OPPS Rate,427.63,1026,
ADMIN IMMUN INITIAL VACCINE,893674,CDM,771,RC,90471,HCPCS,Outpatient,,,202,141.4,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,137.36,68,,109.89,Percent of Total Billed Charges,68% of Total Billed Charges,153.52,76,,1268.29,Percent of Total Billed Charges,76% of Total Billed Charges,101,50,,0.8,Percent of Total Billed Charges,50% of Total Billed Charges,37.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.12,153.52,
ADMINISTRATION-INFLUENZA,600339,CDM,771,RC,90471,HCPCS,Outpatient,,,114,79.8,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,84.4,Percent of Total Billed Charges,50% of Total Billed Charges,37.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.12,86.64,
ADMINISTRATION-PNEUMOCOCCAL,600340,CDM,771,RC,G0009,HCPCS,Outpatient,,,114,79.8,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,77.52,68,,62.02,Percent of Total Billed Charges,68% of Total Billed Charges,86.64,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,57,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,86.64,
INFLUENZA IMM-ADMIN,622264,CDM,771,RC,G0008,HCPCS,Outpatient,,,27,18.9,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,68.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.96,100,,,Fee Schedule,100% of CMS OPPS Rate,13.5,57.99,
HEPATITIS B ADM,641682,CDM,771,RC,Y7506,HCPCS,Outpatient,,,27,18.9,,,,,,Other,Not Seperately Reimbusable,18.36,68,,14.69,Percent of Total Billed Charges,68% of Total Billed Charges,20.52,76,,30.4,Percent of Total Billed Charges,76% of Total Billed Charges,13.5,50,,8.8,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.5,20.52,
ADM/COVID VAC J&J ONE DOSE,707600,CDM,771,RC,0031A,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ADM/COVID VAC MODERNA 1ST DOSE,707900,CDM,771,RC,0011A,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ADM/COVID VAC MODERNA 2ND DOSE,708000,CDM,771,RC,0012A,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ADM/MODERNA BOOSTER VAC,708100,CDM,771,RC,0064A,HCPCS,Outpatient,,,40,28,,,,,,Other,Not Seperately Reimbusable,27.2,68,,21.76,Percent of Total Billed Charges,68% of Total Billed Charges,30.4,76,,24.32,Percent of Total Billed Charges,76% of Total Billed Charges,20,50,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20,30.4,
ADMIN IMMUN INITIAL VACCINE,9047100,CDM,771,RC,90471,HCPCS,Outpatient,,,53,37.1,,24.24,100,,,fee schedule,100% Aetna Market fee schedule,36.04,68,,28.83,Percent of Total Billed Charges,68% of Total Billed Charges,40.28,76,,32.22,Percent of Total Billed Charges,76% of Total Billed Charges,26.5,50,,21.2,Percent of Total Billed Charges,50% of Total Billed Charges,37.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,26.5,86.01,
ADM/EACH ADDITIONAL VACCINE,9047200,CDM,771,RC,90472,HCPCS,Outpatient,,,13,9.1,,12.13,100,,,fee schedule,100% Aetna Market fee schedule,8.84,68,,7.07,Percent of Total Billed Charges,68% of Total Billed Charges,9.88,76,,7.9,Percent of Total Billed Charges,76% of Total Billed Charges,6.5,50,,5.2,Percent of Total Billed Charges,50% of Total Billed Charges,26,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6.5,26,
CHANGE CYSTOSTOMY TUBE COMPLIC,550177,CDM,775,RC,51710,HCPCS,Outpatient,,,226,158.2,,70.28,100,,,fee schedule,100% Aetna Market fee schedule,153.68,68,,122.94,Percent of Total Billed Charges,68% of Total Billed Charges,171.76,76,,20.06,Percent of Total Billed Charges,76% of Total Billed Charges,113,50,,75.6,Percent of Total Billed Charges,50% of Total Billed Charges,150.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,834.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,617.82,100,,,Fee Schedule,100% of CMS OPPS Rate,113,834.05,
CYSTO/URETERO WI/LITHROTRIPSY,540918,CDM,790,RC,52356,HCPCS,Outpatient,,,8462,5923.4,,366.05,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,69.31,Percent of Total Billed Charges,76% of Total Billed Charges,4231,50,,3.6,Percent of Total Billed Charges,50% of Total Billed Charges,782.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,6317.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,972,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,4679.82,100,,,Fee Schedule,100% of CMS OPPS Rate,782.56,6317.76,
LITHOTRIPSY EXTRACORP SW,541069,CDM,790,RC,50590,HCPCS,Outpatient,,,6036,4225.2,,506.72,100,,,fee schedule,100% Aetna Market fee schedule,1290.5,68,,1032.4,Percent of Total Billed Charges,68% of Total Billed Charges,1444.4,76,,9.12,Percent of Total Billed Charges,76% of Total Billed Charges,3018,50,,1145.2,Percent of Total Billed Charges,50% of Total Billed Charges,1081.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4256.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,941,100,,,Fee Schedule,100% of ASC Tier Groupings fee schedule,,,,,Other,Not Seperately Reimbusable,3152.97,100,,,Fee Schedule,100% of CMS OPPS Rate,941,4256.51,
PSYCHIATRIC DIAGNOSTIC EVALUAT,9079100,CDM,900,RC,90791,HCPCS,Outpatient,,,350,245,,155.95,100,,,fee schedule,100% Aetna Market fee schedule,238,68,,190.4,Percent of Total Billed Charges,68% of Total Billed Charges,266,76,,212.8,Percent of Total Billed Charges,76% of Total Billed Charges,175,50,,140,Percent of Total Billed Charges,50% of Total Billed Charges,290.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,100,290.14,
PSYCHOTHERAPY W/PATIENT 30 MIN,9083200,CDM,900,RC,90832,HCPCS,Outpatient,,,151,105.7,,77.98,100,,,fee schedule,100% Aetna Market fee schedule,102.68,68,,82.14,Percent of Total Billed Charges,68% of Total Billed Charges,114.76,76,,91.81,Percent of Total Billed Charges,76% of Total Billed Charges,75.5,50,,60.4,Percent of Total Billed Charges,50% of Total Billed Charges,134.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,75.5,194.66,
PSYTX WITH PT WITH E/M 30 MIN,9083300,CDM,900,RC,90833,HCPCS,Outpatient,,,173,121.1,,83.54,100,,,fee schedule,100% Aetna Market fee schedule,117.64,68,,94.11,Percent of Total Billed Charges,68% of Total Billed Charges,131.48,76,,105.18,Percent of Total Billed Charges,76% of Total Billed Charges,86.5,50,,69.2,Percent of Total Billed Charges,50% of Total Billed Charges,125.06,200,,,Fee Schedule,200% 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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.5,131.48,
PSYCHOTHERAPY W/PATIENT 45 MIN,9083400,CDM,900,RC,90834,HCPCS,Outpatient,,,200,140,,116.97,100,,,fee schedule,100% Aetna Market fee schedule,136,68,,108.8,Percent of Total Billed Charges,68% of Total Billed Charges,152,76,,121.6,Percent of Total Billed Charges,76% of Total Billed Charges,100,50,,80,Percent of Total Billed Charges,50% of Total Billed Charges,177.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,144.19,100,,,Fee Schedule,100% of CMS OPPS Rate,100,194.66,
NEUROSTIM COMP BRAIN 1 HR,61227,CDM,920,RC,95972,HCPCS,Outpatient,,,227,158.9,,37.41,100,,,fee schedule,100% Aetna Market fee schedule,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,1155.52,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,14.4,Percent of Total Billed Charges,50% of Total Billed Charges,76.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,75,172.52,
ANALYSIS NEUROSTIM SIMPLE,550434,CDM,920,RC,95971,HCPCS,Outpatient,,,227,158.9,,36.8,100,,,fee schedule,100% Aetna Market fee schedule,154.36,68,,123.49,Percent of Total Billed Charges,68% of Total Billed Charges,172.52,76,,29.79,Percent of Total Billed Charges,76% of Total Billed Charges,113.5,50,,54.8,Percent of Total Billed Charges,50% of Total Billed Charges,73.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,73.62,172.52,
UROFLOMETRY COMPLEX,5510,CDM,920,RC,51741,HCPCS,Outpatient,,,101,70.7,,4.71,100,,,fee schedule,100% Aetna Market fee schedule,68.68,68,,54.94,Percent of Total Billed Charges,68% of Total Billed Charges,76.76,76,,13.38,Percent of Total Billed Charges,76% of Total Billed Charges,50.5,50,,2,Percent of Total Billed Charges,50% of Total Billed Charges,10.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,383.23,135,,,Fee Schedule,135% of CMS OPPS Rate,260.6,102,,,Fee Schedule,102% MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS rate,260.6,102,,,Fee Schedule,102% of MO Medicaid rate,255.49,100,,,Fee Schedule,100% of MO Medicaid rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,255.49,100,,,Fee Schedule,100% of MO Medicaid Rate,283.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.36,383.23,
ELECTRONIC ANALYSIS-COMPLEX,5607,CDM,920,RC,95972,HCPCS,Outpatient,,,1702,1191.4,,37.41,100,,,fee schedule,100% Aetna Market fee schedule,1157.36,68,,925.89,Percent of Total Billed Charges,68% of Total Billed Charges,1293.52,76,,17.63,Percent of Total Billed Charges,76% of Total Billed Charges,851,50,,1.2,Percent of Total Billed Charges,50% of Total Billed Charges,76.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,75,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,87.54,100,,,Fee Schedule,100% of CMS OPPS Rate,75,1293.52,
NONINV STUDY UPP LOW EXTRE SGL,120200,CDM,921,RC,93922,HCPCS,Outpatient,,,348,243.6,,11.29,100,,,fee schedule,100% Aetna Market fee schedule,236.64,68,,189.31,Percent of Total Billed Charges,68% of Total Billed Charges,264.48,76,,187.68,Percent of Total Billed Charges,76% of Total Billed Charges,174,50,,56.4,Percent of Total Billed Charges,50% of Total Billed Charges,121.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,155.96,135,,,Fee Schedule,135% of CMS OPPS Rate,106.05,102,,,Fee Schedule,102% MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS rate,106.05,102,,,Fee Schedule,102% of MO Medicaid rate,103.97,100,,,Fee Schedule,100% of MO Medicaid rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.97,100,,,Fee Schedule,100% of MO Medicaid Rate,115.53,100,,,Fee Schedule,100% of CMS OPPS Rate,103.97,264.48,
US ARTERIAL UPPER EXTR BILATER,890235,CDM,921,RC,93930,HCPCS,Outpatient,,,368,257.6,,35.57,100,,,fee schedule,100% Aetna Market fee schedule,250.24,68,,200.19,Percent of Total Billed Charges,68% of Total Billed Charges,279.68,76,,223.74,Percent of Total Billed Charges,76% of Total Billed Charges,184,50,,147.2,Percent of Total Billed Charges,50% of Total Billed Charges,275.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,184,299.18,
US EXTRACRANIAL ARTERIES;COMP.,890255,CDM,921,RC,93880,HCPCS,Outpatient,,,449,314.3,TC,35.91,100,,,fee schedule,100% Aetna Market fee schedule,305.32,68,,244.26,Percent of Total Billed Charges,68% of Total Billed Charges,341.24,76,,272.99,Percent of Total Billed Charges,76% of Total Billed Charges,224.5,50,,179.6,Percent of Total Billed Charges,50% of Total Billed Charges,262.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,341.24,
US LOWER EXTREMITY ARTERIES;BI,890360,CDM,921,RC,93925,HCPCS,Outpatient,,,963,674.1,TC,35.33,100,,,fee schedule,100% Aetna Market fee schedule,654.84,68,,523.87,Percent of Total Billed Charges,68% of Total Billed Charges,731.88,76,,585.5,Percent of Total Billed Charges,76% of Total Billed Charges,481.5,50,,385.2,Percent of Total Billed Charges,50% of Total Billed Charges,349.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,731.88,
US EXTREMITY ARTERIES;UNILATER,890365,CDM,921,RC,93926,HCPCS,Outpatient,,,482,337.4,TC,21.45,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,366.32,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,208.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,366.32,
US EXTREMITY ARTERIES;UNILATER,890370,CDM,921,RC,93926,HCPCS,Outpatient,,,482,337.4,TC,21.45,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,366.32,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,208.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,366.32,
US EXTREMITY VEINS;BILATERAL,890375,CDM,921,RC,93970,HCPCS,Outpatient,,,963,674.1,TC,31.19,100,,,fee schedule,100% Aetna Market fee schedule,654.84,68,,523.87,Percent of Total Billed Charges,68% of Total Billed Charges,731.88,76,,585.5,Percent of Total Billed Charges,76% of Total Billed Charges,481.5,50,,385.2,Percent of Total Billed Charges,50% of Total Billed Charges,265.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,299.18,135,,,Fee Schedule,135% of CMS OPPS Rate,203.44,102,,,Fee Schedule,102% MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS rate,203.44,102,,,Fee Schedule,102% of MO Medicaid rate,199.45,100,,,Fee Schedule,100% of MO Medicaid rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.45,100,,,Fee Schedule,100% of MO Medicaid Rate,221.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.45,731.88,
US EXTREMITY VEINS; UNILATERAL,890380,CDM,921,RC,93971,HCPCS,Outpatient,,,482,337.4,TC,19.87,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,366.32,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,168.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,366.32,
US EXTREMITY VEINS; UNILATERAL,890385,CDM,921,RC,93971,HCPCS,Outpatient,,,482,337.4,TC,19.87,100,,,fee schedule,100% Aetna Market fee schedule,327.76,68,,262.21,Percent of Total Billed Charges,68% of Total Billed Charges,366.32,76,,293.06,Percent of Total Billed Charges,76% of Total Billed Charges,241,50,,192.8,Percent of Total Billed Charges,50% of Total Billed Charges,168.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,134.22,135,,,Fee Schedule,135% of CMS OPPS Rate,91.28,102,,,Fee Schedule,102% MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS rate,91.28,102,,,Fee Schedule,102% of MO Medicaid rate,89.49,100,,,Fee Schedule,100% of MO Medicaid rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.49,100,,,Fee Schedule,100% of MO Medicaid Rate,99.43,100,,,Fee Schedule,100% of CMS OPPS Rate,89.49,366.32,
ALVEOLOPLSTY EA QUADRNT SPECIF,893621,CDM,940,RC,41874,HCPCS,Outpatient,,,5690,3983,,221.41,100,,,fee schedule,100% Aetna Market fee schedule,3869.2,68,,3095.36,Percent of Total Billed Charges,68% of Total Billed Charges,4324.4,76,,14.59,Percent of Total Billed Charges,76% of Total Billed Charges,2845,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,452.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,3931.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,2911.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55,4324.4,
FULL THCK HEAD HND 20 SQ CM,893627,CDM,940,RC,15240,HCPCS,Outpatient,,,3452,2416.4,,676.86,100,,,fee schedule,100% Aetna Market fee schedule,2347.36,68,,1877.89,Percent of Total Billed Charges,68% of Total Billed Charges,2623.52,76,,35.87,Percent of Total Billed Charges,76% of Total Billed Charges,1726,50,,8.4,Percent of Total Billed Charges,50% of Total Billed Charges,1476.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,55,2623.52,
FULL THCK HEAD HND 20 SQ CM,893633,CDM,940,RC,15240,HCPCS,Outpatient,,,3452,2416.4,,676.86,100,,,fee schedule,100% Aetna Market fee schedule,2347.36,68,,1877.89,Percent of Total Billed Charges,68% of Total Billed Charges,2623.52,76,,4.86,Percent of Total Billed Charges,76% of Total Billed Charges,1726,50,,8,Percent of Total Billed Charges,50% of Total Billed Charges,1476.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2226.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,1649.33,100,,,Fee Schedule,100% of CMS OPPS Rate,55,2623.52,
IRR IMP VEN ACC DEV DRUG DELIV,5735,CDM,940,RC,96523,HCPCS,Outpatient,,,171,119.7,,24.96,100,,,fee schedule,100% Aetna Market fee schedule,116.28,68,,93.02,Percent of Total Billed Charges,68% of Total Billed Charges,129.96,76,,2.43,Percent of Total Billed Charges,76% of Total Billed Charges,85.5,50,,0.4,Percent of Total Billed Charges,50% of Total Billed Charges,43.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,55.32,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,129.96,
INJECT THER DX SUBCU OR IM,5835,CDM,940,RC,96372,HCPCS,Outpatient,,,181,126.7,,13.09,100,,,fee schedule,100% Aetna Market fee schedule,123.08,68,,98.46,Percent of Total Billed Charges,68% of Total Billed Charges,137.56,76,,45.6,Percent of Total Billed Charges,76% of Total Billed Charges,90.5,50,,3.2,Percent of Total Billed Charges,50% of Total Billed Charges,26.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,55,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,63.71,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,137.56,
DIABETIC EDUC-INDIVIDUAL 30 MI,190025,CDM,942,RC,G0108,HCPCS,Outpatient,,,73,51.1,,50.85,100,,,fee schedule,100% Aetna Market fee schedule,49.64,68,,39.71,Percent of Total Billed Charges,68% of Total Billed Charges,55.48,76,,93.57,Percent of Total Billed Charges,76% of Total Billed Charges,36.5,50,,30.4,Percent of Total Billed Charges,50% of Total Billed Charges,101.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,50.98,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.98,100,,,Fee Schedule,100% of CMS OPPS Rate,25,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,50.98,100,,,Fee Schedule,100% of CMS OPPS Rate,25,101.96,
DIABETIC EDUC-GROUP 30 MIN,190050,CDM,942,RC,G0109,HCPCS,Outpatient,,,49,34.3,,14.44,100,,,fee schedule,100% Aetna Market fee schedule,33.32,68,,26.66,Percent of Total Billed Charges,68% of Total Billed Charges,37.24,76,,337.82,Percent of Total Billed Charges,76% of Total Billed Charges,24.5,50,,25.2,Percent of Total Billed Charges,50% of Total Billed Charges,29.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.65,100,,,Fee Schedule,100% of CMS OPPS rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.65,100,,,Fee Schedule,100% of CMS OPPS Rate,25,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Seperately Reimbusable,14.65,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,37.24,
TOBACCO CESSATION 3-10 MIN,852500,CDM,942,RC,,,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,25.16,68,,20.13,Percent of Total Billed Charges,68% of Total Billed Charges,28.12,76,,22.5,Percent of Total Billed Charges,76% of Total Billed Charges,18.5,50,,14.8,Percent of Total Billed Charges,50% of Total Billed Charges,24.05,65,,19.24,Percent of Total Billed Charges,65% of Total Billed Charges,27.75,75,,22.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,22.2,60,,17.76,Percent of Total Billed Charges,60% of Total Billed Charges,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.55,20.4,,6.04,Percent of Total Billed Charges,20.4% of Total Billed Charges,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,100,,,Case Rate,Pays based on per visit rate,7.4,20,,5.92,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,7.4,28.12,
TOBACCO CESSATION > 10 MIN,852550,CDM,942,RC,,,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,37.4,68,,29.92,Percent of Total Billed Charges,68% of Total Billed Charges,41.8,76,,33.44,Percent of Total Billed Charges,76% of Total Billed Charges,27.5,50,,22,Percent of Total Billed Charges,50% of Total Billed Charges,35.75,65,,28.6,Percent of Total Billed Charges,65% of Total Billed Charges,41.25,75,,33,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,33,60,,26.4,Percent of Total Billed Charges,60% of Total Billed Charges,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11.22,20.4,,8.98,Percent of Total Billed Charges,20.4% of Total Billed Charges,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,25,100,,,Case Rate,Pays based on per visit rate,11,20,,8.8,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,11,41.8,
PULMONARY REHABILITATION,760320,CDM,948,RC,,,Outpatient,,,97,67.9,,,,,,Other,Not Seperately Reimbusable,65.96,68,,52.77,Percent of Total Billed Charges,68% of Total Billed Charges,73.72,76,,58.98,Percent of Total Billed Charges,76% of Total Billed Charges,48.5,50,,38.8,Percent of Total Billed Charges,50% of Total Billed Charges,63.05,65,,50.44,Percent of Total Billed Charges,65% of Total Billed Charges,72.75,75,,58.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,58.2,60,,46.56,Percent of Total Billed Charges,60% of Total Billed Charges,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.79,20.4,,15.83,Percent of Total Billed Charges,20.4% of Total Billed Charges,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.4,20,,15.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,19.4,73.72,
RESPIRATORY STRENGTH-REHAB,760325,CDM,948,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
RESPIRATORY FUNCTION-REHAB,760330,CDM,948,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
PULMONARY REHAB-GROUP,760335,CDM,948,RC,,,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,48.96,68,,39.17,Percent of Total Billed Charges,68% of Total Billed Charges,54.72,76,,43.78,Percent of Total Billed Charges,76% of Total Billed Charges,36,50,,28.8,Percent of Total Billed Charges,50% of Total Billed Charges,46.8,65,,37.44,Percent of Total Billed Charges,65% of Total Billed Charges,54,75,,43.2,Percent of Total Billed Charges,75% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,43.2,60,,34.56,Percent of Total Billed Charges,60% of Total Billed Charges,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.69,20.4,,11.75,Percent of Total Billed Charges,20.4% of Total Billed Charges,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.4,20,,11.52,Percent of Total Billed Charges,20% of Total Billed Charges,,,,,Other,Not Seperately Reimbusable,14.4,54.72,
ELECTROCARDIOGRAM REPORT,323381,CDM,960,RC,93010,HCPCS,Outpatient,,,23,16.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,822.02,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,15.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,15.38,
BRONCHOSPASM READING,852328,CDM,960,RC,94070,HCPCS,Outpatient,,,38,26.6,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,104,Other,Not Seperately Reimbusable,61.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.95,61.9,
US EXT VEINS - UNI RT PROF,890381,CDM,960,RC,93971,HCPCS,Outpatient,,,29,20.3,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2310.4,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,58,
US EXT VEINS - UNI LT PROF,893387,CDM,960,RC,93971,HCPCS,Outpatient,,,29,20.3,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,35.36,Other,Not Seperately Reimbusable,,,,12,Other,Not Seperately Reimbusable,58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29,58,
TUBE THORACOSTOMY,541085,CDM,960,RC,32551,HCPCS,Outpatient,,,453,317.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,155.65,Other,Not Seperately Reimbusable,,,,596,Other,Not Seperately Reimbusable,295.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,147.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.54,295.08,
BIOPSY OF CERVIX,550058,CDM,960,RC,57500,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,43.17,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,142.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,71.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.02,142.04,
BLADDER INSTILLATION,550060,CDM,960,RC,51720,HCPCS,Outpatient,,,203,142.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,141.6,Other,Not Seperately Reimbusable,82.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.39,82.78,
BLADDER IRRIGATION,550070,CDM,960,RC,51700,HCPCS,Outpatient,,,94,65.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,93.2,Other,Not Seperately Reimbusable,57.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.57,57.14,
COMPLEX SPINAL CORD,550090,CDM,960,RC,95972,HCPCS,Outpatient,,,117,81.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,131.33,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,76.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.08,76.16,
LITHOLAPAXY REM OF BLADDER STO,550166,CDM,960,RC,52318,HCPCS,Outpatient,,,1010,707,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,892.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,446.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,602.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.05,892.1,
CREATE PASSAGE TO KIDNEY,550170,CDM,960,RC,52334,HCPCS,Outpatient,,,334,233.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,7.6,Other,Not Seperately Reimbusable,342.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,171.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.46,342.92,
DRAINAGE SCROTUM,550178,CDM,960,RC,54700,HCPCS,Outpatient,,,406,284.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,46.82,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,402.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,201.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.37,402.74,
EXC VARICOCELE,550183,CDM,960,RC,55530,HCPCS,Outpatient,,,524,366.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,666.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,333.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.16,666.32,
EPIDIDYMECTOMY-BILATERAL,550184,CDM,960,RC,54861,HCPCS,Outpatient,,,788,551.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.18,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,1076.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,538.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.21,1076.42,
EXC BENIGN SCALP/NECK/GENITALI,550186,CDM,960,RC,11420,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,152.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,76.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.13,152.26,
INSERT INDWELLING CATH-COMPLIC,550191,CDM,960,RC,51703,HCPCS,Outpatient,,,100,70,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.85,Other,Not Seperately Reimbusable,,,,76.8,Other,Not Seperately Reimbusable,144.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.21,144.42,
EXC BENIGN SCALP/NECK/GENITALI,550192,CDM,960,RC,11426,HCPCS,Outpatient,,,447,312.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,71.74,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,504.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,504.14,
EXC HIP/PELVIS LES SC < 3 CM,550194,CDM,960,RC,27047,HCPCS,Outpatient,,,530,371,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,684.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,462.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,342.29,684.58,
REPAIR BLADDER & VAGINA,550195,CDM,960,RC,57240,HCPCS,Outpatient,,,990,693,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.26,Other,Not Seperately Reimbusable,,,,42,Other,Not Seperately Reimbusable,1165.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,582.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.59,1165.18,
REPAIR OF BLADDER WOUND,550196,CDM,960,RC,51860,HCPCS,Outpatient,,,963,674.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.72,Other,Not Seperately Reimbusable,,,,172.4,Other,Not Seperately Reimbusable,1410.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,952.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,705.27,1410.54,
DILATION OF FEMALE URETHRA,550202,CDM,960,RC,53660,HCPCS,Outpatient,,,87,60.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,78.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,39.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.13,78.26,
REVISION OF TESTIS,550210,CDM,960,RC,54660,HCPCS,Outpatient,,,459,321.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,46.21,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,677.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,338.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,457.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.72,677.44,
DESTROY LUMB/SAC FACET JNT SGL,550220,CDM,960,RC,64635,HCPCS,Outpatient,,,547,382.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.72,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,362.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.22,362.44,
DESTROY LUMB/SAC FACET JNT ADD,550221,CDM,960,RC,64636,HCPCS,Outpatient,,,204,142.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,905.92,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,111.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,55.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.61,111.22,
INJ PROC NEPHROSTOGRAM &/OR UR,550230,CDM,960,RC,50430,HCPCS,Outpatient,,,669,468.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,12.8,Other,Not Seperately Reimbusable,286.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,143.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.47,286.94,
INITIAL HOSP CARE,550240,CDM,960,RC,99223,HCPCS,Outpatient,,,381,266.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,328.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,164.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.39,328.78,
INSERT PESSARY/INTRAVAGINAL DE,550255,CDM,960,RC,57160,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,87.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.88,87.76,
ORCHIECTOMY-INGUINAL,550272,CDM,960,RC,54530,HCPCS,Outpatient,,,701,490.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,7.2,Other,Not Seperately Reimbusable,962.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,481.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,649.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,481.32,962.64,
PLACE RT DEVICE/MARKER PROS,550276,CDM,960,RC,55876,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.3,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,192.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,96.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,96.05,192.1,
RECONSTRUCTION URETHRA,550277,CDM,960,RC,53415,HCPCS,Outpatient,,,1434,1003.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.06,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,2135.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1067.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1441.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1067.59,2135.18,
REM IMPACTED FB VAGINA,550278,CDM,960,RC,57415,HCPCS,Outpatient,,,219,153.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,330.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.33,330.66,
REMOVE BLADDER STONE,550282,CDM,960,RC,52317,HCPCS,Outpatient,,,1044,730.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.26,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,652.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,326.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.25,652.5,
REM MULTI COMP PENILE,550283,CDM,960,RC,54406,HCPCS,Outpatient,,,1399,979.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.38,Other,Not Seperately Reimbusable,,,,30.8,Other,Not Seperately Reimbusable,1384.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,692.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,934.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,692.18,1384.36,
REPAIR INFLAT PENILE PROSTHESI,550285,CDM,960,RC,54408,HCPCS,Outpatient,,,1102,771.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,1496.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,748.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1010.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,748.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,748.32,1496.64,
REV OF SCROTUM,550291,CDM,960,RC,55180,HCPCS,Outpatient,,,885,619.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.59,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1302.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,651.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,879.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,651.21,1302.42,
REV OF SCROTUM SIMPLE,550296,CDM,960,RC,55175,HCPCS,Outpatient,,,466,326.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.54,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,689.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,344.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.91,689.82,
SUBSEQ OBS CARE FOCUSED,550310,CDM,960,RC,99224,HCPCS,Outpatient,,,54,37.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSEQ OBS CARE EXPANDED,550315,CDM,960,RC,99225,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSEQ OBS CARE DETAILED,550320,CDM,960,RC,99226,HCPCS,Outpatient,,,145,101.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TREAT VAG INF,550360,CDM,960,RC,57150,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,49.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.67,49.34,
NEURO/SACRAL NERVE,550401,CDM,960,RC,64561,HCPCS,Outpatient,,,1054,737.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,574.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.42,574.84,
DEST PENIS LESION SIMPLE,550412,CDM,960,RC,54050,HCPCS,Outpatient,,,173,121.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,29.6,Other,Not Seperately Reimbusable,197.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.98,197.96,
CYSTO COMPLICATED,550426,CDM,960,RC,52315,HCPCS,Outpatient,,,561,392.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,68,Other,Not Seperately Reimbusable,516.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,258.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.18,516.36,
REPAIR OF HAMMERTOE,550451,CDM,960,RC,28285,HCPCS,Outpatient,,,719,503.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,728.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,364.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,491.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.04,728.08,
EXC FOOT/TOE TUMOR DEEP<1.5 CM,550455,CDM,960,RC,28045,HCPCS,Outpatient,,,442,309.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.9,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,655.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,327.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,442.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,327.8,655.6,
EXC FOOT/TOE TUMOR SUBCUTAN <1,550456,CDM,960,RC,28043,HCPCS,Outpatient,,,333,233.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.89,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,492.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,492.5,
REMOVAL OF WRIST LESION,550460,CDM,960,RC,25130,HCPCS,Outpatient,,,559,391.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,80.26,Other,Not Seperately Reimbusable,,,,57.2,Other,Not Seperately Reimbusable,851.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,425.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,575.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.98,851.96,
EXC F/E/E/N/L MAL 0.6 CM TO 1.,550464,CDM,960,RC,11641,HCPCS,Outpatient,,,290,203,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,288.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,144.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.46,288.92,
EXC H-F-N-SP BENIGN > 4 CM,550474,CDM,960,RC,11426,HCPCS,Outpatient,,,517,361.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,152,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,504.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,504.14,
CYSTOSCOPY W/REMOVAL OF CLOTS,550475,CDM,960,RC,52001,HCPCS,Outpatient,,,472,330.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,62,Other,Not Seperately Reimbusable,540.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,270.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,364.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.28,540.56,
REMOVAL SWEAT GLAND LESION,550476,CDM,960,RC,11471,HCPCS,Outpatient,,,441,308.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,660.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,330.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.1,660.2,
EGD DIAGNOSTIC BRUSH WASH,550477,CDM,960,RC,43235,HCPCS,Outpatient,,,322,225.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.9,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,229.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.6,229.2,
BONE BX OPEN SUPERFICIAL,550479,CDM,960,RC,20240,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,164.8,Other,Not Seperately Reimbusable,265.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,132.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.92,265.84,
REM DEVITAL TISSUE 20 CM <,550481,CDM,960,RC,97597,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,105.18,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31,62,
DRAINAGE FOREARM LESION,550482,CDM,960,RC,25028,HCPCS,Outpatient,,,653,457.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,82.08,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,1259.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,629.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,850.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.94,1259.88,
LAP ING HERNIA REPAIR,550483,CDM,960,RC,49650,HCPCS,Outpatient,,,551,385.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.9,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,822.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,411.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.16,822.32,
RAD RESECT ABD TUMORE 5CM/>,550485,CDM,960,RC,22905,HCPCS,Outpatient,,,1726,1208.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,2526.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1263.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1705.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1263.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1263.27,2526.54,
EXC TR-EXT BENIGN 2.1-3 CM,550486,CDM,960,RC,11403,HCPCS,Outpatient,,,275,192.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,216.45,Other,Not Seperately Reimbusable,,,,34,Other,Not Seperately Reimbusable,277.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,138.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.91,277.82,
SHAVE SKIN LESION 0.5 CM/<,550488,CDM,960,RC,11310,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,32,Other,Not Seperately Reimbusable,85.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.7,85.4,
DRAINAGE MOUTH LESION,550489,CDM,960,RC,40800,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,217.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.63,217.26,
REM OF SPERM CORD LESION,550495,CDM,960,RC,55520,HCPCS,Outpatient,,,581,406.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.73,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,868.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,434.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,586.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.34,868.68,
SURGERY FOR URETHRA POUCH,550501,CDM,960,RC,53240,HCPCS,Outpatient,,,547,382.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.38,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,803.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,401.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.99,803.98,
KIDNEY ENDOSCOPY,550502,CDM,960,RC,50575,HCPCS,Outpatient,,,935,654.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.89,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,1343.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,671.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,906.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.64,1343.28,
DRAINAGE OF HYDROCELE,550503,CDM,960,RC,55000,HCPCS,Outpatient,,,146,102.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.22,Other,Not Seperately Reimbusable,,,,7.6,Other,Not Seperately Reimbusable,159.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.74,159.48,
REPAIR LIP,550505,CDM,960,RC,40650,HCPCS,Outpatient,,,380,266,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,591.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,295.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295.64,591.28,
REM NAIL BED,550507,CDM,960,RC,11750,HCPCS,Outpatient,,,235,164.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.26,Other,Not Seperately Reimbusable,,,,27.2,Other,Not Seperately Reimbusable,190.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,95.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,128.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.41,190.82,
REM SWEAT GLAND LESIOIN,550508,CDM,960,RC,11450,HCPCS,Outpatient,,,484,338.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,489.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,244.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.98,489.96,
LAPARO LIGATE SPERMATIC VEIN,550515,CDM,960,RC,55550,HCPCS,Outpatient,,,818,572.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,18.4,Other,Not Seperately Reimbusable,813.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,406.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,549.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.88,813.76,
PARTIAL REMOVAL OF COLON,550518,CDM,960,RC,44144,HCPCS,Outpatient,,,3393,2375.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,100.8,Other,Not Seperately Reimbusable,3345.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1672.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,2258.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1672.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1672.7,3345.4,
DEB MUS/FASCIA ADD ON CODE,550520,CDM,960,RC,11046,HCPCS,Outpatient,,,107,74.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.22,Other,Not Seperately Reimbusable,,,,65.6,Other,Not Seperately Reimbusable,104.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,52.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.16,104.32,
LAPARO CHOLECYSTECTOMY/EXPIR,550523,CDM,960,RC,47564,HCPCS,Outpatient,,,2146,1502.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,16,Other,Not Seperately Reimbusable,2128.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1064.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1436.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1064.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1064.12,2128.24,
DILATE ESOPHAGUS 1/MULT PASS,550525,CDM,960,RC,43450,HCPCS,Outpatient,,,199,139.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,148.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,74.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.38,148.76,
SKIN SPLIT A-GRAFT FAC/NCK/H/F,550526,CDM,960,RC,15120,HCPCS,Outpatient,,,1301,910.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,1293.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,646.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,873.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,646.78,1293.56,
PRP I/HERNIA INIT REDU>5 YEAR,550528,CDM,960,RC,49505,HCPCS,Outpatient,,,999,699.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.79,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,994.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,497.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.41,994.82,
EXC TR-EXT BENIGN 0.6-1 CM,550530,CDM,960,RC,11401,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,103.36,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,195.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.83,195.66,
LAP ENTEROLYSIS,550538,CDM,960,RC,44180,HCPCS,Outpatient,,,1767,1236.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.3,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1751.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,875.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1182.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,875.75,1751.5,
DEBRIDE ABD WALL,550541,CDM,960,RC,11005,HCPCS,Outpatient,,,1500,1050,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,138.4,Other,Not Seperately Reimbusable,1472.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,736.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,993.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,736.15,1472.3,
I&D SKIN ABSCESS SIMPLE,550543,CDM,960,RC,10060,HCPCS,Outpatient,,,191,133.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,196.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.29,196.58,
UPPER GI SCOPE W/SUBMUC INJECT,550547,CDM,960,RC,43236,HCPCS,Outpatient,,,445,311.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.3,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,259.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,129.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.6,259.2,
CYSTO/TMT,550549,CDM,960,RC,52300,HCPCS,Outpatient,,,536,375.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,52.8,Other,Not Seperately Reimbusable,526.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,263.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,355.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,263.22,526.44,
PARTIAL REMOVAL OF TOE,550553,CDM,960,RC,28126,HCPCS,Outpatient,,,698,488.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,472.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,236.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.25,472.5,
REM CV CATH,550556,CDM,960,RC,36590,HCPCS,Outpatient,,,361,252.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,354.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,177.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.31,354.62,
LAP LYSIS,550560,CDM,960,RC,58660,HCPCS,Outpatient,,,1308,915.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,1306.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,653.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,882.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,653.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,653.47,1306.94,
LAP VENT/ABD HERN,550561,CDM,960,RC,49653,HCPCS,Outpatient,,,1787,1250.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PART REMOVAL METATARSAL,550562,CDM,960,RC,28112,HCPCS,Outpatient,,,598,418.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,19.6,Other,Not Seperately Reimbusable,590,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,295,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,295,590,
RELIEVE BLADDER CONTRACTURE,550563,CDM,960,RC,52640,HCPCS,Outpatient,,,774,541.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,91.2,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,606.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,303.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,303.2,606.4,
INCISION OF ANAL SPINCTER,550564,CDM,960,RC,46080,HCPCS,Outpatient,,,329,230.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,52.9,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,299.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.52,299.04,
REM INT/EXT HEM 1 GROUP,550565,CDM,960,RC,46255,HCPCS,Outpatient,,,678,474.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,94.24,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,666.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,333.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.36,666.72,
SKIN FULL GRAFT TRUNK,550566,CDM,960,RC,15200,HCPCS,Outpatient,,,1257,879.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,1256.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,628.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,848.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.28,1256.56,
COLONOSCOPY THRU STOMA,550567,CDM,960,RC,44388,HCPCS,Outpatient,,,393,275.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,155.6,Other,Not Seperately Reimbusable,292.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,146.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.44,292.88,
TREATMENT OF FOOT INFECTION,550569,CDM,960,RC,28002,HCPCS,Outpatient,,,602,421.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,250.5,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,267.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,133.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.86,267.72,
REMOVAL/DEVITAL TISSUE 20 CM<,550570,CDM,960,RC,97597,HCPCS,Outpatient,,,116,81.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,33.44,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,67.72,
EXC F/E/E/N/L MAL MRG 1.1 CM T,550777,CDM,960,RC,11642,HCPCS,Outpatient,,,290,203,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.71,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,338.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,169.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.43,338.86,
INJ ANSTH CELIAC PLEXUS,5601,CDM,960,RC,64530,HCPCS,Outpatient,,,261,182.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,177.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,88.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.62,177.24,
INJ ANSTH ORTH PERIPHERAL NERV,5602,CDM,960,RC,64450,HCPCS,Outpatient,,,116,81.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,79.2,
ANL SP INF PMP W/MDREPRG&FIL,5603,CDM,960,RC,62370,HCPCS,Outpatient,,,129,90.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.14,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,86.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.49,86.98,
LUMBAR/CAUDAL EPIDURAL,6000,CDM,960,RC,62322,HCPCS,Outpatient,,,509,356.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,150.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,150.8,
EPIDUROGRAPHY INTERPRETATION,6001,CDM,960,RC,72275,HCPCS,Outpatient,,,31,21.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INJ SACROILIAC JOINT ARTHOGRAP,6002,CDM,960,RC,27096,HCPCS,Outpatient,,,230,161,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,156.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,78.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.1,156.2,
SACROILIAC JOINT XRAY INTERPRE,6003,CDM,960,RC,73542,HCPCS,Outpatient,,,25,17.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INJ DX THX AGNT VRTVRFCT LS JN,6004,CDM,960,RC,64493,HCPCS,Outpatient,,,143,100.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,18.85,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,169.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.91,169.82,
INJ DX THX AGNT VRTBRFCT LS JN,6005,CDM,960,RC,64494,HCPCS,Outpatient,,,143,100.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,42.56,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,96.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.25,96.5,
FLUOROSCOPY NEEDLE SPINE,6006,CDM,960,RC,77003,HCPCS,Outpatient,,,279,195.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,132.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,66.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.09,132.18,
IP CONSULT-BRIEF,6007,CDM,960,RC,99251,HCPCS,Outpatient,,,109,76.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
IP CONSULT-EXPANDED,6008,CDM,960,RC,99252,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,135.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,67.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.71,135.42,
IP CONSULT-DETAILED,6009,CDM,960,RC,99253,HCPCS,Outpatient,,,182,127.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,20,Other,Not Seperately Reimbusable,188.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.48,188.96,
IP CONSULT-COMP/MODERATE,6010,CDM,960,RC,99254,HCPCS,Outpatient,,,237,165.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,140.4,Other,Not Seperately Reimbusable,261.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.9,261.8,
IP CONSULT-COMP/HIGH,6011,CDM,960,RC,99255,HCPCS,Outpatient,,,273,191.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,50.4,Other,Not Seperately Reimbusable,354.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,177.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.12,354.24,
EPIDURAL INJ CERVICAL/THORACES,6012,CDM,960,RC,62320,HCPCS,Outpatient,,,503,352.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,47.2,Other,Not Seperately Reimbusable,189.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.61,189.22,
NJX AA&/STRD INTERCOSTAL NRV E,6013,CDM,960,RC,64421,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,47.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,47.38,
INJ ANSTH TRANS EPI LUM SGL LV,6014,CDM,960,RC,64483,HCPCS,Outpatient,,,305,213.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,68,Other,Not Seperately Reimbusable,209.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.53,209.06,
INJ EPIDURAL BLOOD PATCH,6015,CDM,960,RC,62273,HCPCS,Outpatient,,,124,86.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3837.2,Other,Not Seperately Reimbusable,214.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,107.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.29,214.58,
INJ FACET JOINT CERVICAL/THORA,6016,CDM,960,RC,64470,HCPCS,Outpatient,,,303,212.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INJ DX THX AGNT VRTBRFCT CT JN,6017,CDM,960,RC,64490,HCPCS,Outpatient,,,290,203,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,45.6,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,198.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.01,198.02,
INJ TRIGGER POINT 1-2 MUSCL,6018,CDM,960,RC,20552,HCPCS,Outpatient,,,103,72.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,50.46,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,69.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.85,69.7,
INJ FOR KNEE ARTHROGRAPHY,6019,CDM,960,RC,27370,HCPCS,Outpatient,,,303,212.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EXAMINATION-KNEE,6020,CDM,960,RC,73580,HCPCS,Outpatient,,,28,19.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28,56,
ARTHRO ASPIR SMALL JOINT WO GU,6021,CDM,960,RC,20600,HCPCS,Outpatient,,,99,69.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,68.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.03,68.06,
ARTHRO ASPIR INTERMED JNTS WO,6022,CDM,960,RC,20605,HCPCS,Outpatient,,,104,72.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4.8,Other,Not Seperately Reimbusable,69.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,69.96,
ARTHRO ASPIR MAJOR JOINTS WO G,6023,CDM,960,RC,20610,HCPCS,Outpatient,,,126,88.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,86.18,
INJ ANSTH TRANS EPI LUM EA ADD,6024,CDM,960,RC,64484,HCPCS,Outpatient,,,144,100.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,44.8,Other,Not Seperately Reimbusable,97.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.82,97.64,
INJ DX THX AGNT VRTBRFCT LS JN,6025,CDM,960,RC,64495,HCPCS,Outpatient,,,145,101.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,23.2,Other,Not Seperately Reimbusable,98.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,49.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.11,98.22,
NJX INTERLAMINAR CRV/THRC W GU,6026,CDM,960,RC,62321,HCPCS,Outpatient,,,296,207.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,202.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,101.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.38,202.76,
NJX INTERLAMINAR LMBR/SAC W GU,6027,CDM,960,RC,62323,HCPCS,Outpatient,,,274,191.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,834.4,Other,Not Seperately Reimbusable,187.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,126.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.77,187.54,
INJ TRIGGER POINT 3+ MUSCL,6028,CDM,960,RC,20553,HCPCS,Outpatient,,,118,82.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.01,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,79.2,
DSTR NROLYTC AGNT PVB FCT SNGL,6029,CDM,960,RC,64633,HCPCS,Outpatient,,,528,369.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,43.17,Other,Not Seperately Reimbusable,,,,80.8,Other,Not Seperately Reimbusable,361.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.93,361.86,
INJ ANSTH GRTER OCCIPITAL NERV,6030,CDM,960,RC,64405,HCPCS,Outpatient,,,148,103.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.18,Other,Not Seperately Reimbusable,,,,58.4,Other,Not Seperately Reimbusable,100.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,50.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.43,100.86,
INJ THER CARPAL TUNNEL,6031,CDM,960,RC,20526,HCPCS,Outpatient,,,158,110.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,157.47,Other,Not Seperately Reimbusable,,,,37.2,Other,Not Seperately Reimbusable,107.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.67,107.34,
RF ABLTJ NRV NRVTG SI JT,6032,CDM,960,RC,64625,HCPCS,Outpatient,,,538,376.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,368.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,184.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.12,368.24,
INJ ANSTH ILIOINGUINAL NERVES,6033,CDM,960,RC,64425,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,114.4,Other,Not Seperately Reimbusable,102.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,51.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.39,102.78,
NJX INTERLAMINAR LMBR/SAC WO G,6034,CDM,960,RC,62322,HCPCS,Outpatient,,,225,157.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,150.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,150.8,
TONSILLECTOMY <12,7500,CDM,960,RC,42825,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,67.2,Other,Not Seperately Reimbusable,504,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252,504,
TONSILLECTOMY >12,7501,CDM,960,RC,42826,HCPCS,Outpatient,,,310,217,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,28.8,Other,Not Seperately Reimbusable,481.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,240.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.56,481.12,
TYMPANOSTOMY,7502,CDM,960,RC,69436,HCPCS,Outpatient,,,198,138.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.5,Other,Not Seperately Reimbusable,,,,16,Other,Not Seperately Reimbusable,297.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,148.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.93,297.86,
T & A >12,7504,CDM,960,RC,42821,HCPCS,Outpatient,,,376,263.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,198,Other,Not Seperately Reimbusable,574.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,387.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.08,574.16,
DEBRID OPEN WND FIRST 20 SQ CM,9005,CDM,960,RC,97597,HCPCS,Outpatient,,,99,69.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.61,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,67.72,
DEBRID OPEN WND EA ADDTL 20 SQ,9006,CDM,960,RC,97598,HCPCS,Outpatient,,,34,23.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.73,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,46.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.45,46.9,
OP CONSULTATION,9019,CDM,960,RC,99242,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,105.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,52.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.8,105.6,
INJ DX THX AGNT VRTBRFCT CT JN,550226,CDM,960,RC,64490,HCPCS,Outpatient,,,290,203,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,198.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.01,198.02,
INJ DX THX AGNT VRTBRFCT CT JN,550227,CDM,960,RC,64491,HCPCS,Outpatient,,,166,116.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,34.66,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,112.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.22,112.44,
INJ DX THX AGNT VRTBRFCT CT JN,550228,CDM,960,RC,64492,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,114.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.08,114.16,
INJ TENDON SHEATH LIGAMENT,550231,CDM,960,RC,20550,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,74.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.07,74.14,
NJX AA&/STRD INTERCOSTAL NRV S,560004,CDM,960,RC,64420,HCPCS,Outpatient,,,163,114.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,109.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.91,109.82,
NJX AA&/STRD INTERCOSTAL NRV E,560006,CDM,960,RC,64421,HCPCS,Outpatient,,,68,47.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.02,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,47.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.69,47.38,
DSTR NROLYTC AGNT PVB FCT SNGL,893613,CDM,960,RC,64635,HCPCS,Outpatient,,,529,370.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,35.26,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,362.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,244.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.22,362.44,
OUTPATIENT CONSULTATION,550466,CDM,960,RC,99213,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,125.04,
CENTRAL LINE PLACEMENT,550467,CDM,960,RC,36556,HCPCS,Outpatient,,,255,178.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,160.58,
HOSPITAL DISCHARGE DAY,740111,CDM,960,RC,99239,HCPCS,Outpatient,,,200,140,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,107.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.88,215.76,
INSRT TEMP INDWL BLAD CATH SIM,740750,CDM,960,RC,51702,HCPCS,Outpatient,,,116,81.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.02,48.04,
HOSPITAL DISCHARGE DAY,740992,CDM,960,RC,99238,HCPCS,Outpatient,,,136,95.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,76.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.37,152.74,
OUTPATIENT NEW CONSULTATION,740999,CDM,960,RC,99203,HCPCS,Outpatient,,,134,93.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.89,155.78,
OUTPATIENT EST CONSULTATION,741001,CDM,960,RC,99213,HCPCS,Outpatient,,,129,90.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,125.04,
INITIAL HOSP CARE LEVEL 1,741006,CDM,960,RC,99221,HCPCS,Outpatient,,,192,134.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,78.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.68,157.36,
ABD PARACENTESIS,741051,CDM,960,RC,49082,HCPCS,Outpatient,,,243,170.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.88,137.76,
CHANGE TRACHEOSTOMY TUBE,741053,CDM,960,RC,31502,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.13,66.26,
EGD REMOVE LESION SNARE,741055,CDM,960,RC,43251,HCPCS,Outpatient,,,571,399.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,183.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.16,366.32,
SKIN SPLIT GRFT TRUNK/ARM/LEG,741057,CDM,960,RC,15100,HCPCS,Outpatient,,,1344,940.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1337.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,668.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,903.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.91,1337.82,
REREPAIR VENTRL HERN BLCOK,741058,CDM,960,RC,49566,HCPCS,Outpatient,,,1802,1261.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DIAG LARYNGOSCOPY,741059,CDM,960,RC,31575,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.85,127.7,
FNA BX W/US GDN 1ST LES,741060,CDM,960,RC,10005,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,69.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.22,138.44,
PERQ DEV BREAST 1ST US IMAG,741061,CDM,960,RC,19285,HCPCS,Outpatient,,,534,373.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.25,158.5,
INSERT TUNNELED CV CATH,741063,CDM,960,RC,36561,HCPCS,Outpatient,,,1271,889.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,622.7,
EKG INTER & REPORT,323391,CDM,960,RC,93010,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,15.38,
"ECHO READING,PHYSICIAN FEE",890182,CDM,960,RC,93307,HCPCS,Outpatient,,,215,150.5,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,161.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.71,161.42,
ECHO READING,890183,CDM,960,RC,93306,HCPCS,Outpatient,,,369,258.3,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,110.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.77,221.54,
US EXTRACRANIAL ARTERIES PROF,890270,CDM,960,RC,93880,HCPCS,Outpatient,,,356,249.2,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,131.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.07,262.14,
US LOWER EXT -BILATERAL PROF,890363,CDM,960,RC,93925,HCPCS,Outpatient,,,451,315.7,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,174.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,235.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.57,349.14,
US EXT ARTERIES- UNI RT PROF,890364,CDM,960,RC,93926,HCPCS,Outpatient,,,266,186.2,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.19,208.38,
US EXT ARTERIES - UNI LT PROF,890371,CDM,960,RC,93926,HCPCS,Outpatient,,,266,186.2,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,208.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.19,208.38,
US EXT VEINS - BILATERAL PROF,890377,CDM,960,RC,93970,HCPCS,Outpatient,,,348,243.6,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,265.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,132.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.79,265.58,
APPLICATION MULTI LAYER WOUND,8525,CDM,960,RC,29581,HCPCS,Outpatient,,,102,71.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.44,50.88,
DEBRID SUBQ TISSUE ADD ON PHYS,8526,CDM,960,RC,11045,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,48.18,
DEBRID BONE 1ST 20 SQCM PHYS F,8527,CDM,960,RC,11044,HCPCS,Outpatient,,,432,302.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,427.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.92,427.84,
DEBRIDEMENT-MUSCLE/FASCIA 20 S,8529,CDM,960,RC,11043,HCPCS,Outpatient,,,435,304.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,145.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.16,290.32,
DEBRID TISSUE 1ST 20 SQCM PHYS,9004,CDM,960,RC,11042,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,113.98,
ANES TRANSURETHRALPROC NOS MD,7110,CDM,963,RC,910,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES VAG COLPTMY VAGINCTMY COL,7130,CDM,963,RC,942,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANORECTAL,7208,CDM,963,RC,902,HCPCS,Outpatient,,,6,4.2,AA,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES COMBINED UPPER AND LOWER,7241,CDM,963,RC,813,HCPCS,Outpatient,,,6,4.2,AA,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRNSUR FRAG MNIP REM URET,7276,CDM,963,RC,918,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES PROC MALE GENITALIA NOS,7333,CDM,963,RC,920,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES LOW ABD INC URINARY TRACT,7334,CDM,963,RC,860,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRNSURTHRL RESECT PROSTAT,7335,CDM,963,RC,914,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES ANORECTAL PROC,8109,CDM,963,RC,902,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAR/VERT ARTERY CATH,6982,CDM,964,RC,36100,HCPCS,Outpatient,,,438,306.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,288.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,144.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,194.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.21,288.42,
RETRO BRACH ART CATH,6983,CDM,964,RC,36120,HCPCS,Outpatient,,,338,236.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RETRO EXTREM ART CAT,6984,CDM,964,RC,36140,HCPCS,Outpatient,,,338,236.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,167.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.98,167.96,
PERCUTAN VENOUS CATH,6985,CDM,964,RC,36489,HCPCS,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
IMAGE GUIDE ON SPINE,6987,CDM,964,RC,1936,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANESTHESIA COMP BY EMERGENCY C,6990,CDM,964,RC,99140,HCPCS,Outpatient,,,121,84.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HEAD/SAL GLANDS NOS,7000,CDM,964,RC,100,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PLAST REP CLEFT LIP,7001,CDM,964,RC,102,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ELECTROCONVULSIVE TH,7002,CDM,964,RC,104,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EX/MID/INNER EAR NOS,7003,CDM,964,RC,120,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OTOSCOPY,7004,CDM,964,RC,124,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TYMPANOTOMY,7005,CDM,964,RC,126,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EYE NOS,7006,CDM,964,RC,140,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LENS SURGERY,7007,CDM,964,RC,142,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CORNEAL TRANSPLANT,7008,CDM,964,RC,144,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RECONSTRUCTION OF EYELID,7009,CDM,964,RC,103,HCPCS,Outpatient,,,20,14,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
IRIDECTOMY,7010,CDM,964,RC,147,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPHTHALMOSCOPY,7011,CDM,964,RC,148,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NOSE/ACC SINUSES NOS,7012,CDM,964,RC,160,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL SURGERY,7013,CDM,964,RC,162,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BIOPSY/SOFT TISSUE,7014,CDM,964,RC,164,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES INTRORAL PROC INC BX NOS,7015,CDM,964,RC,170,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
REPAIR CLEFT PALATE,7016,CDM,964,RC,172,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EXC RETROPHARYNGAEL,7017,CDM,964,RC,174,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL SURGERY,7018,CDM,964,RC,176,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
FACIAL BONES NOS,7019,CDM,964,RC,190,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL SURGERY,7020,CDM,964,RC,192,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTRACRANIAL NOS,7021,CDM,964,RC,210,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBDURAL TAPS,7022,CDM,964,RC,212,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BURR HOLES,7023,CDM,964,RC,214,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VASCULAR PROCEDURES,7024,CDM,964,RC,216,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SITTING POSITION,7025,CDM,964,RC,218,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SPINAL FLD SHUNTING,7026,CDM,964,RC,220,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ELECTROCOAGULATION,7027,CDM,964,RC,222,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES INTEGM SYS HD NCK POSTR T,7028,CDM,964,RC,300,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NECK NOS,7029,CDM,964,RC,320,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NDL BIOPSY THYROID,7030,CDM,964,RC,322,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MAJ VESSELS/NECK NOS,7031,CDM,964,RC,350,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SIMPLE LIGATION,7032,CDM,964,RC,352,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES INTEGUMENTARY SYS ETREMIT,7033,CDM,964,RC,400,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RECONSTUCTIVE/BREAST,7034,CDM,964,RC,402,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD/MOD RAD BREAST,7035,CDM,964,RC,404,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INT MAMMARY NODE DIS,7036,CDM,964,RC,406,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ELEC CONV/ARRHYTHMIA,7037,CDM,964,RC,410,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER 2/3 OF FEMUR,7038,CDM,964,RC,1220,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLAVICLE/SCAPULA NOS,7039,CDM,964,RC,450,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL SURGERY,7040,CDM,964,RC,452,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BIOPSY CLAVICLE,7041,CDM,964,RC,454,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PART RIB RESECT NOS,7042,CDM,964,RC,470,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
THORACOPLASTY,7043,CDM,964,RC,472,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL PROCEDURES,7044,CDM,964,RC,474,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ESOPHAGUS,7045,CDM,964,RC,500,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED CHEST NOS,7046,CDM,964,RC,520,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NDL BIOPSY/PLEURA,7047,CDM,964,RC,522,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PNEUMOCENTESIS,7048,CDM,964,RC,524,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MEDIASTINOSCOPY,7049,CDM,964,RC,528,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TRANSVENOUS PACEMAKE,7050,CDM,964,RC,530,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ACC CENT VENOUS CIRC,7051,CDM,964,RC,532,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
THORACOTOMY NOS,7052,CDM,964,RC,540,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DECORTICATION,7053,CDM,964,RC,542,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PLEURECTOMY,7054,CDM,964,RC,544,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PULM RESEC/THORACOPL,7055,CDM,964,RC,546,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTRATHORACIC REPAIR,7056,CDM,964,RC,548,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HEART W/O OXYGENATOR,7057,CDM,964,RC,560,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HEART W/OXYGENATOR,7058,CDM,964,RC,562,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HEART TRANSPLANT,7059,CDM,964,RC,580,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CERVICAL SPINE NOS,7060,CDM,964,RC,600,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PSTR CERV LAMINECTOM,7061,CDM,964,RC,604,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
THORACIC SPINE NOS,7062,CDM,964,RC,620,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
THORACOLUMBAR SYMPAT,7063,CDM,964,RC,622,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANESPROC IN LUMBAR REGION NOS,7064,CDM,964,RC,630,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LUMBAR SYMPATHECTOMY,7065,CDM,964,RC,632,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CHEMONUCLEOLYSIS,7066,CDM,964,RC,634,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EXTENSIVE SPINE,7067,CDM,964,RC,670,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER ANTR ABD NOS,7068,CDM,964,RC,700,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PERCUTAN. LIVER BIOP,7069,CDM,964,RC,702,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER POSTR ABD WALL,7070,CDM,964,RC,730,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER GASTRO.ENDOSCO,7071,CDM,964,RC,731,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HERNIA/UPR ABD NOS,7072,CDM,964,RC,750,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LUMBAR/VENTRAL HERNI,7073,CDM,964,RC,752,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OMPHALOCELE,7074,CDM,964,RC,754,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TRANSABD DIAPH HERNI,7075,CDM,964,RC,756,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MAJ ABD BLOOD VESSEL,7076,CDM,964,RC,770,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES LAPROSCOPIC CHOLECT,7077,CDM,964,RC,790,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PARTIAL HEPATECTOMY,7078,CDM,964,RC,792,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PANCREATECTOMY,7079,CDM,964,RC,794,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LIVER TRANSPLANT,7080,CDM,964,RC,796,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANESPROC LOWER ANTER ABD WALL,7081,CDM,964,RC,800,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PANNICULECTOMY,7082,CDM,964,RC,802,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NERVE BLOCK PRONE POSITION,7083,CDM,964,RC,1992,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
"ANES LOW GI ENDO,SCOPE DISTAL",7084,CDM,964,RC,811,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LWR POSTR ABD WALL,7085,CDM,964,RC,820,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES HERNIA REPAIRS LOWER ABD,7086,CDM,964,RC,830,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES VENTRAL HERN 1 MIN,7087,CDM,964,RC,832,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES INTRAPERITONEAL LOWR ABD,7088,CDM,964,RC,840,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
AMNIOCENTESIS,7089,CDM,964,RC,842,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ABDOMINOPERINEAL RES,7090,CDM,964,RC,844,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL HYSTERECTOMY,7091,CDM,964,RC,846,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PELVIC EXENTERATION,7092,CDM,964,RC,848,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CESAREAN SECTION,7093,CDM,964,RC,1961,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TUBAL LIGATION/TRANSECTION,7094,CDM,964,RC,851,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES LOW ABD INC URINARY TRACT,7096,CDM,964,RC,860,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RENAL PROCEDURES,7097,CDM,964,RC,862,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADRENALECTOMY,7099,CDM,964,RC,866,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RENAL TRANSPLANT,7100,CDM,964,RC,868,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CYSTOLITHOTOMY,7101,CDM,964,RC,870,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LITHOTRIPSY W/WATER,7102,CDM,964,RC,872,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES LITH EXTRACORP SHOCKWV WO,7103,CDM,964,RC,873,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MAJ LWR ADB VESSELS,7104,CDM,964,RC,880,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INFR VENA CAVA LIGAT,7105,CDM,964,RC,882,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DELIVERY/BIRTHING RESUSCITATIO,7106,CDM,964,RC,99465,HCPCS,Outpatient,,,275,192.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,269.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.89,269.78,
DELETED CODE,7107,CDM,964,RC,,,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANORECTAL,7108,CDM,964,RC,902,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL PERINEAL,7109,CDM,964,RC,904,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PERINEAL PROSTATECTO,7111,CDM,964,RC,908,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRANSURETHRALPROC NOS,7112,CDM,964,RC,910,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRANSURETHRAL RESECT BLDD,7113,CDM,964,RC,912,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRNSURTHRL RESECT PROSTAT,7114,CDM,964,RC,914,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
POST TR/URT RESC BLD,7115,CDM,964,RC,916,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES TRNSUR FRAG MNIP REM URET,7116,CDM,964,RC,918,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES PROC MALE GENITALIA NOS,7117,CDM,964,RC,920,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SEMINAL VESICLES,7118,CDM,964,RC,922,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UNDESCENDED TESTIS,7119,CDM,964,RC,924,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD ORCHIECTOMY INGU,7120,CDM,964,RC,926,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD ORCHIECTOMY ABD,7121,CDM,964,RC,928,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ORCHIOPEXY UNI/BILAT,7122,CDM,964,RC,930,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
COMP AMPUTAT PENIS,7123,CDM,964,RC,932,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD AMP PENIS/LYMPHA,7124,CDM,964,RC,934,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD AMP PENIS/ILIAC,7125,CDM,964,RC,936,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES INSRT PENILE PROSTHS PERI,7126,CDM,964,RC,938,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES VAGINAL PROC 1 MIN,7127,CDM,964,RC,940,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES VAG COLPTMY VAGINCTMY COL,7128,CDM,964,RC,942,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VAGINAL HYSTERECTOMY,7129,CDM,964,RC,944,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CERVICAL CERCLAGE,7131,CDM,964,RC,948,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CULDOSCOPY,7132,CDM,964,RC,950,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HYSTEROSCOPY,7133,CDM,964,RC,952,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CONT EPIDURAL-VAGINA,7134,CDM,964,RC,1967,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BONY PELVIS,7137,CDM,964,RC,1120,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BODY CAST APPLICATIO,7138,CDM,964,RC,1130,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTERPELVIABDOM AMP,7139,CDM,964,RC,1140,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL TUMOR-PELVIS,7140,CDM,964,RC,1150,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED SACROILIAC JT,7141,CDM,964,RC,1160,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN SACROILIAC JNT,7142,CDM,964,RC,1170,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OBTURATOR NEURECTOMY,7143,CDM,964,RC,1180,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTRAPELVIC,7144,CDM,964,RC,1190,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED HIP JOINT,7145,CDM,964,RC,1200,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTHROSCOPIC HIP JT,7146,CDM,964,RC,1202,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN HIP JOINT NOS,7147,CDM,964,RC,1210,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HIP DISARTICULATION,7148,CDM,964,RC,1212,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN UPPER FEMUR NOS,7151,CDM,964,RC,1230,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
AMPUTATION,7152,CDM,964,RC,1232,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL RESECTION,7153,CDM,964,RC,1234,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NER/MUS/TEND UP LEG,7155,CDM,964,RC,1250,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS UPPER LEG,7156,CDM,964,RC,1260,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIES UP LEG NOS,7157,CDM,964,RC,1270,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
FEMORAL ARTERY LIGAT,7158,CDM,964,RC,1272,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
FEMORAL ARTERY EMBOL,7159,CDM,964,RC,1274,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DIAG/THER NERVE BLOCK/INJ PRON,7160,CDM,964,RC,1992,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NER/MUS/TEND KNEE,7161,CDM,964,RC,1320,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED LOWER FEMUR,7162,CDM,964,RC,1340,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN LOWER FEMUR,7163,CDM,964,RC,1360,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED KNEE JOINT,7164,CDM,964,RC,1380,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTHROSCOPIC KNEE JT,7165,CDM,964,RC,1382,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLSD UP ENDS TIB/FIB,7166,CDM,964,RC,1390,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPN UP ENDS TIB/FIB,7167,CDM,964,RC,1392,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPN KNEE JOINT NOS,7168,CDM,964,RC,1400,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL KNEE REPLACEMT,7169,CDM,964,RC,1402,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DISARTICULATION KNEE,7170,CDM,964,RC,1404,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAST KNEE JOINT,7171,CDM,964,RC,1420,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS KNEE NOS,7172,CDM,964,RC,1430,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIOVENOUS FISTUL,7173,CDM,964,RC,1432,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIES KNEE NOS,7174,CDM,964,RC,1440,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
POPLITEAL THROMBOEND,7175,CDM,964,RC,1442,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
POPLITEAL EXCIS/GRAF,7176,CDM,964,RC,1444,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED LOWER L/A/F,7178,CDM,964,RC,1462,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTHROSCOPIC ANKLE J,7179,CDM,964,RC,1464,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES KNEE/ANKLE/FOOT,7180,CDM,964,RC,1470,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RUPTURED ACHILLES TE,7181,CDM,964,RC,1472,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
GASTROCNEMIUS RECESS,7182,CDM,964,RC,1474,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES OPEN BONES LOW LEG ANKL F,7183,CDM,964,RC,1480,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL RESECTION,7184,CDM,964,RC,1482,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OSTEOTOMY/PLASTY T/F,7185,CDM,964,RC,1484,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL ANKLE REPLACMT,7186,CDM,964,RC,1486,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LWR LEG CAST,7187,CDM,964,RC,1490,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIES LWR LEG NOS,7188,CDM,964,RC,1500,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EMBOLECTOMY,7189,CDM,964,RC,1502,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS LWR LEG NOS,7190,CDM,964,RC,1520,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VENOUS THROMBECTOMY,7191,CDM,964,RC,1522,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSD HUMRL HEAD/NEC,7194,CDM,964,RC,1620,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTHROSCOPIC SHOULDE,7195,CDM,964,RC,1622,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL RESECTION,7197,CDM,964,RC,1632,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SHOULDER DISARTICULA,7198,CDM,964,RC,1634,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
FOREQUARTER AMPUTATI,7199,CDM,964,RC,1636,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL SHLDR REPLACMT,7200,CDM,964,RC,1638,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIES SHLDR NOS,7201,CDM,964,RC,1650,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
AXILLARY/BRACHIAL AN,7202,CDM,964,RC,1652,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BYPASS GRAFT,7203,CDM,964,RC,1654,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
AXILL/FEMORAL BYPASS,7204,CDM,964,RC,1656,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS SHLDR & AXILLA,7205,CDM,964,RC,1670,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SHOULDER CAST,7206,CDM,964,RC,1680,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SHOULDER SPICA,7207,CDM,964,RC,1682,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES ARM/ELBOW 1 MIN,7209,CDM,964,RC,1710,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TENOTOMY ELB/SHLD OP,7210,CDM,964,RC,1712,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TENOPLASTY ELB/SHLD,7211,CDM,964,RC,1714,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TENODESIS RUPT TENDN,7212,CDM,964,RC,1716,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HUMERUS/ELBOW CLOSED,7213,CDM,964,RC,1730,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTHROSCOPIC ELBW JT,7214,CDM,964,RC,1732,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HUMERUS/ELB OPEN NOS,7215,CDM,964,RC,1740,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OSTEOTOMY HUMERUS,7216,CDM,964,RC,1742,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
REP NON/MALUNION HUM,7217,CDM,964,RC,1744,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RADICAL PROCEDURES,7218,CDM,964,RC,1756,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EXCISN CYST HUMERUS,7219,CDM,964,RC,1758,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTL ELBOW REPLACEMT,7220,CDM,964,RC,1760,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ART UPPR ARM/ELB NOS,7221,CDM,964,RC,1770,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EMBOLECTOMY,7222,CDM,964,RC,1772,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS UPPR ARM/ELB N,7223,CDM,964,RC,1780,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PHLEBORRHAPHY,7224,CDM,964,RC,1782,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES NRV MSCL TND FSC BRS FRAR,7227,CDM,964,RC,1810,HCPCS,Outpatient,,,6,4.2,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD/ULNA/WRST/HND CL,7228,CDM,964,RC,1820,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
RAD/ULNA/WRST/HND OP,7229,CDM,964,RC,1830,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL WRIST REPLACMN,7230,CDM,964,RC,1832,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ART FRARM/WRST/HND,7231,CDM,964,RC,1840,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EMBOLECTOMY,7232,CDM,964,RC,1842,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VASCULAR SHUNT,7233,CDM,964,RC,1844,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VEINS FRARM/WRST/HND,7234,CDM,964,RC,1850,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PHLEBORRHAPHY,7235,CDM,964,RC,1852,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
FRARM/WRST/HAND CAST,7236,CDM,964,RC,1860,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES SCRNING COLONOSCOPY SCOPE,7238,CDM,964,RC,812,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES COMBINED UPPER AND LOWER,7240,CDM,964,RC,813,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ARTERIOGRAMS/NDL/C-V,7245,CDM,964,RC,1916,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CARDIAC CATHETERIZAT,7247,CDM,964,RC,1920,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES NON-INVSIV IMAG OR RADN T,7249,CDM,964,RC,1922,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PHYSLGCAL SUP/HARVST,7250,CDM,964,RC,1990,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
REG IV ADM/LCL ANEST,7251,CDM,964,RC,1995,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DLY MGMT EPIDURAL AD,7252,CDM,964,RC,1996,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UNLISTED ANESTHESIA,7253,CDM,964,RC,1999,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INSERT SUBCL LINE,7254,CDM,964,RC,36488,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VENIPUNTURE < 3YR,7255,CDM,964,RC,36400,HCPCS,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,35.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.62,35.24,
VENI/CUTDOWN <1,7256,CDM,964,RC,36420,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,,,,10,Other,Not Seperately Reimbusable,91.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,45.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.9,91.8,
VENIPUNCTURE >1,7257,CDM,964,RC,36425,HCPCS,Outpatient,,,366,256.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,74.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.44,74.88,
EPIDURAL CATHETER DURING LABOR,7258,CDM,964,RC,1967,HCPCS,Outpatient,,,413,289.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INSERT VENOUS CATH >5YRS,7259,CDM,964,RC,36556,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,18.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14,28,
ARTERIAL PUNCTURE,7260,CDM,964,RC,36600,HCPCS,Outpatient,,,119,83.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,28.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.15,28.3,
ARTERIAL CATHERIZAT,7261,CDM,964,RC,36620,HCPCS,Outpatient,,,366,256.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,84.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.21,84.42,
ARTERIAL CATH/CUTDWN,7262,CDM,964,RC,36625,HCPCS,Outpatient,,,1051,735.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,199.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,99.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.8,199.6,
CATH/UMBILIC ARTERY,7263,CDM,964,RC,36660,HCPCS,Outpatient,,,1051,735.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,128.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,64.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.42,128.84,
SPINAL/LUMBAR DIAG,7264,CDM,964,RC,62270,HCPCS,Outpatient,,,1051,735.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,122.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.08,122.16,
INJ-LUMBAR EPIDURAL,7265,CDM,964,RC,62273,HCPCS,Outpatient,,,1734,1213.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,214.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,107.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.29,214.58,
TRANSVENOUS INS/REPL PACING CA,7266,CDM,964,RC,534,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BURN DEBRIDMENT-2ND & 3RD DEGR,7267,CDM,964,RC,1951,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES MALE GENITALIA VASECTOMY,7268,CDM,964,RC,921,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
COLPORRHAPHY,7269,CDM,964,RC,942,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MANIPULATION THORACIC OR LUMBA,7270,CDM,964,RC,640,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DRESSING CHANGE,7272,CDM,964,RC,1582,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INCOMPLETE ABORTION,7275,CDM,964,RC,1965,HCPCS,Outpatient,,,14,9.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LENS SURGERY,8007,CDM,964,RC,142,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTEGUMENTARY S/NECK,8028,CDM,964,RC,300,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANTERIOR CHEST NOS,8033,CDM,964,RC,400,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED CHEST NOS,8046,CDM,964,RC,520,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER GASTRO ENDOSCO,8071,CDM,964,RC,740,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LUMBAR/VENTRAL HERNI,8073,CDM,964,RC,752,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTRAPRTONEAL UP/ABD,8077,CDM,964,RC,790,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INTESTINAL ENDOSCOPIC,8084,CDM,964,RC,810,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
HERNIA/LWR ABD NOS,8086,CDM,964,RC,830,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CESAREAN SECTION,8093,CDM,964,RC,1961,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL CYSTECTOMY,8098,CDM,964,RC,864,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES ANORECTAL PROC,8108,CDM,964,RC,902,HCPCS,Outpatient,,,6,4.2,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TRANSURETHRAL PR NOS,8112,CDM,964,RC,910,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
VAGINAL PROC NOS,8127,CDM,964,RC,940,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLOSED UPPER FEMUR,8150,CDM,964,RC,1220,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LOWER LEG/ANKLE/FOOT,8177,CDM,964,RC,400,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NER/MUS/TN LWR L/A/F,8180,CDM,964,RC,1470,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN LWR L/A/F NOS,8183,CDM,964,RC,1480,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NER/MUS/TEN SHOULDER,8193,CDM,964,RC,1610,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OPEN HUMRL HEAD/NECK,8196,CDM,964,RC,1630,HCPCS,Outpatient,,,6,4.2,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NER/MUS/TEND F-W-HND,8227,CDM,964,RC,1810,HCPCS,Outpatient,,,14,9.8,QS,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
UPPER GASTRO ENDOSCO,9071,CDM,964,RC,740,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
LUMBAR/VENTRAL HERNI,9073,CDM,964,RC,752,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CESAREAN SECTION,9093,CDM,964,RC,1961,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TOTAL HIP REPLACEMEN,9149,CDM,964,RC,1214,HCPCS,Outpatient,,,14,9.8,QZ,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES HERNIA UPPER ABD NOS,893616,CDM,964,RC,750,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
URETHROLYSIS TRANSVAG W/ SCOPE,893419,CDM,964,RC,53500,HCPCS,Outpatient,,,527,368.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,1054,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,527,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,711.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,527,1054,
ANES PROC UPPER POSTERIOR ABD,893660,CDM,964,RC,730,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ANES RECONSTUC PROC EYELID,893661,CDM,964,RC,103,HCPCS,Outpatient,,,6,4.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MOD SED SAME PHYS/QHP 5/>YRS,540990,CDM,969,RC,99152,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,217.6,Other,Not Seperately Reimbusable,,,,12.4,Other,Not Seperately Reimbusable,23.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,23.16,
MOD SED SAME PHYS/QHP EA,540991,CDM,969,RC,99153,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,102.4,Other,Not Seperately Reimbusable,20.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,20.16,
CHOLANGIO INTRAOPRTV,550105,CDM,972,RC,74300,HCPCS,Outpatient,,,60,42,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DESTRUCTION LESIONS VULVA SIMP,5400,CDM,975,RC,56501,HCPCS,Outpatient,,,375,262.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,64.45,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,248.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.14,248.28,
TRURL RESCJ RESID REGROW OBST,5401,CDM,975,RC,52630,HCPCS,Outpatient,,,1148,803.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,128.29,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,765.22,
NEUROSTIM COMP BRAIN 1 HR,61233,CDM,975,RC,95972,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,773.2,Other,Not Seperately Reimbusable,76.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.08,76.16,
SMPL RPR SCP-NK-GN-TRNK-XTRM 7,540101,CDM,975,RC,12004,HCPCS,Outpatient,,,197,137.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,326.4,Other,Not Seperately Reimbusable,141.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.77,141.54,
REPAIR INTERMEDIATE S/A/T/E 12,540103,CDM,975,RC,12035,HCPCS,Outpatient,,,478,334.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,2157.2,Other,Not Seperately Reimbusable,451.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,225.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.85,451.7,
CMPLX RPR SCALP ARM  LG 2.6-7.,540105,CDM,975,RC,13121,HCPCS,Outpatient,,,512,358.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,480.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,240.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.17,480.34,
CMPLX RPR SCALO ARM LG EA ADD,540107,CDM,975,RC,13122,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,155.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.65,155.3,
INSERT PERIPHERAL CV ACC DEV,540109,CDM,975,RC,36571,HCPCS,Outpatient,,,631,441.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,326.4,Other,Not Seperately Reimbusable,587.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,293.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.58,587.16,
EXC TUM SFT TISS NECK ANT THRX,540926,CDM,975,RC,21552,HCPCS,Outpatient,,,895,626.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,847.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,423.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,572.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,423.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,423.97,847.94,
CMPLX RPR FACE NCK GEN HND FT,540928,CDM,975,RC,13132,HCPCS,Outpatient,,,621,434.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,563.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,281.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.88,563.76,
CMPL RPR FACE NCK AX GEN HND F,540930,CDM,975,RC,13133,HCPCS,Outpatient,,,255,178.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,5479.6,Other,Not Seperately Reimbusable,235.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,117.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,158.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.75,235.5,
CMPL RPR SCALP ARM LG 2.6-705,540980,CDM,975,RC,13121,HCPCS,Outpatient,,,512,358.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,324,Other,Not Seperately Reimbusable,480.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,240.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,324.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.17,480.34,
SRG PREP GRFT INI 100 CM TRNK,540981,CDM,975,RC,15002,HCPCS,Outpatient,,,449,314.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,412.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,206.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,278.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.37,412.74,
SRG PREP GRFT ADL 100 CM TRNK,540982,CDM,975,RC,15003,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,10.8,Other,Not Seperately Reimbusable,85.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.75,85.5,
"SKIN GRFT SPLIT TRK,ARM,LEF 1S",540983,CDM,975,RC,15100,HCPCS,Outpatient,,,1414,989.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,939.2,Other,Not Seperately Reimbusable,1337.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,668.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,903.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,668.91,1337.82,
SPLT GRFT TRUNK EA 100 SQ CM,540984,CDM,975,RC,15101,HCPCS,Outpatient,,,226,158.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,207.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.88,207.76,
EXCIS TUM UPPER ARM ELBOW IM,540985,CDM,975,RC,24076,HCPCS,Outpatient,,,1079,755.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,66,Other,Not Seperately Reimbusable,1033.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,516.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,697.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.51,1033.02,
"AMPUTATN,FT;MIDTARSAL",540986,CDM,975,RC,28800,HCPCS,Outpatient,,,1063,744.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,26,Other,Not Seperately Reimbusable,998.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,499.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,673.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,499.11,998.22,
INSERT NON TUNNEL CV CATH 5+,540987,CDM,975,RC,36556,HCPCS,Outpatient,,,174,121.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,33.2,Other,Not Seperately Reimbusable,160.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,160.58,
EGD CONTROL BLEEDING,540988,CDM,975,RC,43255,HCPCS,Outpatient,,,573,401.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,167.2,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,373.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,186.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.98,373.96,
SIGMOID FLEX REM TUM SNARE,540989,CDM,975,RC,45338,HCPCS,Outpatient,,,287,200.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.9,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,224.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,112.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.41,224.82,
EXCIS OF CYST FIBROADENOMA 1+L,541000,CDM,975,RC,19120,HCPCS,Outpatient,,,834,583.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,790.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,395.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,533.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,395.41,790.82,
ALVEOLOPLSTY EA QUADRNT SPECIF,541001,CDM,975,RC,41874,HCPCS,Outpatient,,,483,338.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,452.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,226.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.19,452.38,
EDG REMOVE TUM SNARE,541002,CDM,975,RC,43251,HCPCS,Outpatient,,,465,325.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,366.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,183.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.16,366.32,
INCIS PERIANAL ABSCESS SUPE,541014,CDM,975,RC,46050,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,189.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.52,189.04,
FLUOROSCOPY UP TO 1 HOUR,541015,CDM,975,RC,76000,HCPCS,Outpatient,,,89,62.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,707.71,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,48.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.47,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.05,48.1,
UNLISTED PROC DENTOALVEOLAR ST,541016,CDM,975,RC,41899,HCPCS,Outpatient,,,234,163.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
ADJ TIS TRN FORE 10 CM,541017,CDM,975,RC,14040,HCPCS,Outpatient,,,1208,845.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,6.4,Other,Not Seperately Reimbusable,1160.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,580.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,783.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,580.21,1160.42,
EXCIS TUM SFT TISS UPPR ARM SU,541019,CDM,975,RC,24071,HCPCS,Outpatient,,,811,567.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,515.78,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,767.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,383.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,518.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,383.96,767.92,
AMPUTATN OF FINGER/THUMB,541021,CDM,975,RC,26952,HCPCS,Outpatient,,,1270,889,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,33.6,Other,Not Seperately Reimbusable,1259.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,629.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,850.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,629.87,1259.74,
I & D HEMA SEROMA FLUID,541029,CDM,975,RC,10140,HCPCS,Outpatient,,,231,161.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1155.52,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,220.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,110.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110.3,220.6,
REMV SLF CONTAIND PENIL PRSTHS,541030,CDM,975,RC,54415,HCPCS,Outpatient,,,1052,736.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,122.82,Other,Not Seperately Reimbusable,,,,86.4,Other,Not Seperately Reimbusable,1006.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,503.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,679.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,503.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,503.43,1006.86,
UNLSTD LAPAROSCOPIC PROC LIVER,541039,CDM,975,RC,47379,HCPCS,Outpatient,,,1724,1206.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
URETAL TUM RESECTN,541040,CDM,975,RC,52355,HCPCS,Outpatient,,,943,660.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,879.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,439.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,593.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,439.94,879.88,
I&D POST OP WND ENFECT COMP,541047,CDM,975,RC,10180,HCPCS,Outpatient,,,486,340.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,33.44,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,333.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,166.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.86,333.72,
REPR ABDOMINAL WALL,541048,CDM,975,RC,49900,HCPCS,Outpatient,,,1659,1161.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1560.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,780.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1053.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,780.09,1560.18,
BIOPSY OF PENIS DEEP STRUCTURE,541049,CDM,975,RC,54105,HCPCS,Outpatient,,,522,365.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,401.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,200.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.97,401.94,
DEBRID REMOVE FORN MAT SBQ,541062,CDM,975,RC,11012,HCPCS,Outpatient,,,844,590.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,132.54,Other,Not Seperately Reimbusable,,,,37.6,Other,Not Seperately Reimbusable,783.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,391.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.93,783.86,
EXCIS SFT TUM BACK FLANK SUBQ,541063,CDM,975,RC,21931,HCPCS,Outpatient,,,948,663.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,814.11,Other,Not Seperately Reimbusable,,,,18.8,Other,Not Seperately Reimbusable,891.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,445.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,601.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,445.74,891.48,
CLTX ULNAR FX PROXIMAL END,541064,CDM,975,RC,24675,HCPCS,Outpatient,,,812,568.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,69.31,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,795.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,397.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.69,795.38,
REAMPUTATN OF THIGH THRU FEMUR,541065,CDM,975,RC,27596,HCPCS,Outpatient,,,1452,1016.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,69.31,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,1346.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,673.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,908.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,673.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,673.04,1346.08,
LARYNGOSCOPY DIAGNOSTIC,541066,CDM,975,RC,31525,HCPCS,Outpatient,,,316,221.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,301.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,150.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.8,301.6,
INSRTN PENL PROSTHES NON FLATA,541067,CDM,975,RC,54400,HCPCS,Outpatient,,,1141,798.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.89,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1007.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,503.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,680.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,503.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,503.72,1007.44,
DESTR LES PENIS ELECTRO SIMP,541068,CDM,975,RC,54055,HCPCS,Outpatient,,,180,126,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,178.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.36,178.72,
"IMAG GUID FLUID COLLCTN CATH,",541078,CDM,975,RC,10030,HCPCS,Outpatient,,,278,194.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,255.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,127.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.61,255.22,
EXC LES TENDON SHEATH FT,541079,CDM,975,RC,28090,HCPCS,Outpatient,,,600,420,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.32,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,581.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,290.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.79,581.58,
REMOVAL OF FOREIGN BODY FT DEE,541080,CDM,975,RC,28192,HCPCS,Outpatient,,,613,429.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.52,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,584.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,292.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,394.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.36,584.72,
EXC SOFT TIS TUM UPARM ELBOW,541081,CDM,975,RC,25075,HCPCS,Outpatient,,,620,434,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,50.46,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,595.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,297.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.68,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.54,595.08,
INSERT TUN CENT CATH VEN DEVIC,541082,CDM,975,RC,36561,HCPCS,Outpatient,,,680,476,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.01,Other,Not Seperately Reimbusable,,,,14.8,Other,Not Seperately Reimbusable,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,622.7,
LITHOTRIPSY EXTRACORP SW,541083,CDM,975,RC,50590,HCPCS,Outpatient,,,1134,793.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.81,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,1081.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,540.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,730.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,540.87,1081.74,
DESTRUCTION LESIONS VULVA SIMP,541088,CDM,975,RC,56501,HCPCS,Outpatient,,,375,262.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,248.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.14,248.28,
TRURL RESCJ RESID REGROW OBST,541089,CDM,975,RC,52630,HCPCS,Outpatient,,,1148,803.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,765.22,
DIRECT LARYNGOSCOPE W/VC INJ,541134,CDM,975,RC,31570,HCPCS,Outpatient,,,540,378,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,431.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,215.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.74,431.48,
EXC DENTOALVEOLAR LES W/O RPR,541765,CDM,975,RC,41825,HCPCS,Outpatient,,,228,159.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.73,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,224.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,112.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.17,224.34,
ORCHIOPEXY INGUN/SCROT APPR,546401,CDM,975,RC,54640,HCPCS,Outpatient,,,450,315,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.02,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,819.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,409.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,552.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,409.61,819.22,
PERC IMPLONT NEUROSTIM SAC NRV,550050,CDM,975,RC,64561,HCPCS,Outpatient,,,592,414.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,574.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,287.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,287.42,574.84,
ANT COLPORRHAPHY RPR CYSTCEL W,550055,CDM,975,RC,57240,HCPCS,Outpatient,,,1175,822.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,51.07,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,1165.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,582.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,786.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.59,1165.18,
BIOPSY PENIS,550057,CDM,975,RC,54100,HCPCS,Outpatient,,,239,167.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,130.11,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,227.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.51,227.02,
CIRCUMCISION,550077,CDM,975,RC,54161,HCPCS,Outpatient,,,382,267.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,372.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,186.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,251.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.39,372.78,
COLPOPEXY EXTRAPERITONEAL,550080,CDM,975,RC,57282,HCPCS,Outpatient,,,1331,931.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,1319.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,659.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,890.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,659.77,1319.54,
CYSTOURETHRSCPY W LITHOTRIPSY,550100,CDM,975,RC,52353,HCPCS,Outpatient,,,790,553,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,179.36,Other,Not Seperately Reimbusable,,,,74,Other,Not Seperately Reimbusable,737.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,368.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.69,737.38,
CYSTOURETHROSCOPY W DIL BLADDE,550110,CDM,975,RC,52260,HCPCS,Outpatient,,,424,296.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,396.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,198.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.12,396.24,
REOAUR CIROIREAK TEAR,550111,CDM,975,RC,54437,HCPCS,Outpatient,,,1343,940.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,1283,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,641.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,866.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.5,1283,
CYSTO & URETER CATH,550130,CDM,975,RC,52005,HCPCS,Outpatient,,,264,184.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,250.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,125.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.17,250.34,
CYSTO W URET PYELOSC BX FULG O,550135,CDM,975,RC,52354,HCPCS,Outpatient,,,841,588.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,784.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,529.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.43,784.86,
CYSTOURETHROSCOPY (SEPERAT PRO,550140,CDM,975,RC,52000,HCPCS,Outpatient,,,196,137.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,151.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.96,151.92,
CYSTOURETHROSCOPY COMPLICATED,550145,CDM,975,RC,52318,HCPCS,Outpatient,,,1010,707,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,892.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,446.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,602.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,446.05,892.1,
CYSTOURETHRSCPY W/INSERT INDW,550150,CDM,975,RC,52332,HCPCS,Outpatient,,,360,252,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,71.74,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,292.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,146.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,146.1,292.2,
CYSTOURETHROS W URETERSCOP DIA,550155,CDM,975,RC,52351,HCPCS,Outpatient,,,591,413.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.79,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,570.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,285.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,384.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,285.04,570.08,
CYSTOURETERO W STONE REMOVAL,550160,CDM,975,RC,52352,HCPCS,Outpatient,,,715,500.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,17.2,Other,Not Seperately Reimbusable,666.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,333.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.05,666.1,
CYSTOURETHROSCOPY RFB SIMPLE,550165,CDM,975,RC,52310,HCPCS,Outpatient,,,431,301.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,262,Other,Not Seperately Reimbusable,285.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.62,285.24,
LITHOLAPAXY REM OF BLADDER STO,550167,CDM,975,RC,52317,HCPCS,Outpatient,,,765,535.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,652.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,326.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.25,652.5,
CYSTO W FULG AND RESET TUMOR,550175,CDM,975,RC,52234,HCPCS,Outpatient,,,554,387.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,205.2,Other,Not Seperately Reimbusable,462.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,231.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.13,462.26,
EXCIS HYDROCEL SPERMATIC CORD,550179,CDM,975,RC,55500,HCPCS,Outpatient,,,759,531.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,52,Other,Not Seperately Reimbusable,740.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,370.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,500.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.41,740.82,
ASPIR BLAD WINSERT SUPRAP CATH,550180,CDM,975,RC,51102,HCPCS,Outpatient,,,284,198.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,2.8,Other,Not Seperately Reimbusable,269.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.6,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.52,269.04,
EXCISN OF HYDROCELE UNILATERAL,550181,CDM,975,RC,55040,HCPCS,Outpatient,,,668,467.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.15,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,640.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,320.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.2,640.4,
EXCISN OF HYDROCELE BILATERAL,550182,CDM,975,RC,55041,HCPCS,Outpatient,,,1017,711.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.58,Other,Not Seperately Reimbusable,,,,23.2,Other,Not Seperately Reimbusable,968.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,484.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,653.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,484.27,968.54,
CYSTO W FULG WO W BX,550185,CDM,975,RC,52224,HCPCS,Outpatient,,,401,280.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,382.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,191.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.3,382.6,
CYSTO W/FULG AND OR RESECT BLA,550187,CDM,975,RC,52235,HCPCS,Outpatient,,,821,574.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,542.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,271.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.43,542.86,
CYSTOURETHROSCOPY W BIOPSY(S),550188,CDM,975,RC,52204,HCPCS,Outpatient,,,283,198.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1740.7,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,266.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,133.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.18,266.36,
EXC SPERMATOCELE,550193,CDM,975,RC,54840,HCPCS,Outpatient,,,637,445.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,375.6,Other,Not Seperately Reimbusable,609.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,304.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.54,609.08,
RPR ENTEROCELE VAG APPRCH SEP,550197,CDM,975,RC,57268,HCPCS,Outpatient,,,988,691.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,957,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,478.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,645.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.5,957,
CYSTOURETHROSCPY W CALIB DILAT,550200,CDM,975,RC,52281,HCPCS,Outpatient,,,304,212.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,285.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,142.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,192.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,142.88,285.76,
CYSTOSCOPY AND TRTMENT,550205,CDM,975,RC,52240,HCPCS,Outpatient,,,1213,849.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.5,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,737.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,368.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,498.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,368.98,737.96,
INCIS IMPLANT NEUROSTIM SAC NR,550225,CDM,975,RC,64581,HCPCS,Outpatient,,,703,492.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1249.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,624.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,843.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,624.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,624.7,1249.4,
INSERT REPL PERIPH GI NEUROSTI,550250,CDM,975,RC,64590,HCPCS,Outpatient,,,470,329,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,558.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,279.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,376.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.21,558.42,
INSERT MULTI CMPNT INFLAT PENL,550252,CDM,975,RC,54405,HCPCS,Outpatient,,,1717,1201.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,1529.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,764.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1032.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,764.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,764.57,1529.14,
"INSRT MESH, PRSTH PELVC FLR DF",550257,CDM,975,RC,57267,HCPCS,Outpatient,,,517,361.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,478.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,239.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.08,478.16,
PENIS PLASTIC SURGERY,550265,CDM,975,RC,54360,HCPCS,Outpatient,,,1442,1009.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,15.6,Other,Not Seperately Reimbusable,1364.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,682.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,921.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,682.44,1364.88,
ORCHIECTOMY SIMP WO W TESTIC P,550270,CDM,975,RC,54520,HCPCS,Outpatient,,,647,452.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,620.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,310.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,419.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,310.42,620.84,
POSTR COLPORRHAPHY RPR RCTCEL,550274,CDM,975,RC,57250,HCPCS,Outpatient,,,1221,854.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,52.8,Other,Not Seperately Reimbusable,1170.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,585.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,789.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.11,1170.22,
BIOPSY PROSTATE NEEDLE PUNCH,550275,CDM,975,RC,55700,HCPCS,Outpatient,,,263,184.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,45.6,Other,Not Seperately Reimbusable,246.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,123.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.29,246.58,
RAD RESCT TUM SFT TISS UP-ARM/,550279,CDM,975,RC,24077,HCPCS,Outpatient,,,2011,1407.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,1946.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,973.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1313.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,973.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,973.21,1946.42,
RMVL REVSN SLING STRESS INCONT,550280,CDM,975,RC,57287,HCPCS,Outpatient,,,1421,994.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,54.4,Other,Not Seperately Reimbusable,1399.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,699.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,944.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,699.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,699.55,1399.1,
COMBINED ANTEROPOSTERIOR COLPO,550289,CDM,975,RC,57260,HCPCS,Outpatient,,,1561,1092.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,83.6,Other,Not Seperately Reimbusable,1483.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,741.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1001.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.52,1483.04,
REVIS RMV PERIF GASTR NEUROSTI,550290,CDM,975,RC,64595,HCPCS,Outpatient,,,242,169.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,100,Other,Not Seperately Reimbusable,433.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,216.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.94,433.88,
REVERSE REMOVE NEUROELECTRODES,550292,CDM,975,RC,64585,HCPCS,Outpatient,,,275,192.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,269.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.86,269.72,
REVISE VAG GRAFT VIA VAGINA,550295,CDM,975,RC,57295,HCPCS,Outpatient,,,1440,1008,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,579.2,Other,Not Seperately Reimbusable,949.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,474.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,474.85,949.7,
REVISION OF PENIS,550298,CDM,975,RC,54304,HCPCS,Outpatient,,,780,546,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,215.23,Other,Not Seperately Reimbusable,,,,69.2,Other,Not Seperately Reimbusable,1414.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,707.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,954.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,707.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,707.32,1414.64,
SLING OPERATN FOR STRESS INCON,550300,CDM,975,RC,57288,HCPCS,Outpatient,,,1422,995.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,141.66,Other,Not Seperately Reimbusable,,,,54,Other,Not Seperately Reimbusable,1410.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,705.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,951.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,705.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,705.09,1410.18,
SLING OPRATION CORRJ MALE URIN,550305,CDM,975,RC,53440,HCPCS,Outpatient,,,1506,1054.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,83.3,Other,Not Seperately Reimbusable,,,,55.2,Other,Not Seperately Reimbusable,1424.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,712.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,961.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,712.3,1424.6,
TRANSURETHRAL RESECT PROSTATE,550325,CDM,975,RC,52601,HCPCS,Outpatient,,,1422,995.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,112.48,Other,Not Seperately Reimbusable,,,,488.4,Other,Not Seperately Reimbusable,1378.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,689.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,930.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,689.27,1378.54,
TRANSURETHRAL RESECT BLADDER N,550355,CDM,975,RC,52500,HCPCS,Outpatient,,,970,679,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.59,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,931.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,465.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.83,931.66,
EXC MAL LES TRNK XTRM GRT 4.0,550367,CDM,975,RC,11606,HCPCS,Outpatient,,,633,443.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,2.8,Other,Not Seperately Reimbusable,594.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,297.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.39,594.78,
FULL THCK ARM LEG 20 SQ CM,550369,CDM,975,RC,15220,HCPCS,Outpatient,,,1184,828.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,1133.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,566.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,765.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,566.93,1133.86,
EGD INJ SCLEROSIS,550371,CDM,975,RC,43243,HCPCS,Outpatient,,,566,396.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.14,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,445.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,222.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,300.59,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.66,445.32,
RMV RPLC CMPNT INFLATBLE PENL,550373,CDM,975,RC,54410,HCPCS,Outpatient,,,1721,1204.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,398.24,Other,Not Seperately Reimbusable,,,,21.2,Other,Not Seperately Reimbusable,1632.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,816.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1102.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,816.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,816.33,1632.66,
VASECTOMY,550375,CDM,975,RC,55250,HCPCS,Outpatient,,,446,312.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.38,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,431,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,215.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.5,431,
RMVL/REVJ SLING MALE URINARY I,550377,CDM,975,RC,53442,HCPCS,Outpatient,,,1563,1094.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,2.8,Other,Not Seperately Reimbusable,1484.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,742.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1002.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.4,1484.8,
COLORECTAL SCRN; NOT HI RISK I,550380,CDM,975,RC,45378,HCPCS,Outpatient,,,527,368.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,114.91,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,345.48,
EXC B9 SCLP NK HND FT GN 1.1-2,550382,CDM,975,RC,11422,HCPCS,Outpatient,,,376,263.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,79.04,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,251.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.92,251.84,
REPAIR INTRMDIATE N/H/F/XTRNL,550384,CDM,975,RC,12041,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,270.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.23,270.46,
LARYNGOSCOPY DIRECT W BX,550386,CDM,975,RC,31535,HCPCS,Outpatient,,,536,375.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,355.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,177.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,240.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.86,355.72,
LITHO/INSERTION URETERAL STENT,550400,CDM,975,RC,52356,HCPCS,Outpatient,,,797,557.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,33.44,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,782.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,391.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.28,782.56,
DEST PENIS LESION,550402,CDM,975,RC,54065,HCPCS,Outpatient,,,332,232.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,320.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,160.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.41,320.82,
FLUOROSCOPY NEEDLE BIO ASPIR,550415,CDM,975,RC,77002,HCPCS,Outpatient,,,279,195.3,26,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,145.31,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,153.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.95,153.9,
REPLAC GTUBE REVJ GSTRST TRC,550423,CDM,975,RC,43763,HCPCS,Outpatient,,,315,220.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,164.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,82.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.28,164.56,
CYSTO W/DIRECT VISION INTERP,550425,CDM,975,RC,52276,HCPCS,Outpatient,,,568,397.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,262.05,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,496.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,248.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.42,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.46,496.92,
REPLAC GASTRO TUBE PERQ WO GUI,550429,CDM,975,RC,43762,HCPCS,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,14.59,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,71.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,71.58,
CHOLECYSTECTOMY W/CHOLANGIOGRA,550431,CDM,975,RC,47605,HCPCS,Outpatient,,,2317,1621.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,2145.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1072.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1448.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1072.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1072.97,2145.94,
FLUORO GUID CENT VEN DEV IMP,550433,CDM,975,RC,77001,HCPCS,Outpatient,,,172,120.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,139.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,69.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.52,139.04,
ANALYSIS NEUROSTIM SIMPLE,550435,CDM,975,RC,95971,HCPCS,Outpatient,,,82,57.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,73.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,36.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,49.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.81,73.62,
CYSTOSCOPY W/TRT URETERAL ST,550450,CDM,975,RC,52341,HCPCS,Outpatient,,,572,400.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,534.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,267.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,360.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.25,534.5,
PARTL EXCIS BONE PHALANX OF TO,550452,CDM,975,RC,28124,HCPCS,Outpatient,,,648,453.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,630.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,315.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,425.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,315.13,630.26,
HALLUX VALGUS CORRECTN,550453,CDM,975,RC,28292,HCPCS,Outpatient,,,948,663.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,917.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,458.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,619.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.65,917.3,
AMPUTATION TOE INTERPHALANGEAL,550454,CDM,975,RC,28825,HCPCS,Outpatient,,,456,319.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,330.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.36,330.72,
EGD FLEXIBLE TRANSORAL W BX SN,550457,CDM,975,RC,43239,HCPCS,Outpatient,,,365,255.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.71,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,259.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,129.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,129.6,259.2,
COLON CA SCRN NOT HI RISK INDI,550458,CDM,975,RC,45378,HCPCS,Outpatient,,,527,368.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,7.6,Other,Not Seperately Reimbusable,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,345.48,
COLNSCPY FLEX SPLEN TUM BX,550459,CDM,975,RC,45384,HCPCS,Outpatient,,,592,414.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.94,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,428.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,214.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.19,428.38,
COLONOSCOPY W/LESION REM BY SN,550461,CDM,975,RC,45385,HCPCS,Outpatient,,,710,497,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,69.31,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,475.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,237.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.76,475.52,
REP UMB HERNIA INCARCERATED/ST,550462,CDM,975,RC,49587,HCPCS,Outpatient,,,968,677.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
I&D ABSCESS MULT OR COMP,550463,CDM,975,RC,10061,HCPCS,Outpatient,,,353,247.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.7,343.4,
EXC B9 LESION MRGN XCP SK TG T,550465,CDM,975,RC,11402,HCPCS,Outpatient,,,221,154.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.06,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,214.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,107.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.32,214.64,
DIAGNOSTIC SIGMOIDOSCOPY,550468,CDM,975,RC,45330,HCPCS,Outpatient,,,131,91.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,82.69,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,105.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,52.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.72,105.44,
EGD CAUTERY TUMOR POLYP,550469,CDM,975,RC,43250,HCPCS,Outpatient,,,499,349.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.71,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,318.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.41,318.82,
CMPLX RPR E/N/E/L 2.6 -7.5 CM,550470,CDM,975,RC,13152,HCPCS,Outpatient,,,624,436.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,46.82,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,625.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,312.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,312.95,625.9,
LAPAROSCOPIC CHOLECYSTECTOMY,550471,CDM,975,RC,47563,HCPCS,Outpatient,,,1402,981.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,105.18,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1367.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,683.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,923.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,683.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,683.95,1367.9,
EGD W/PEG PLACEMENT,550472,CDM,975,RC,43246,HCPCS,Outpatient,,,544,380.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,376.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,188.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.09,376.18,
I&D VULVA/PERINEAL ABS,550473,CDM,975,RC,56405,HCPCS,Outpatient,,,233,163.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,127.07,Other,Not Seperately Reimbusable,,,,60,Other,Not Seperately Reimbusable,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,236.06,
AMPUTATN FT TRANSMETATARSAL,550478,CDM,975,RC,28805,HCPCS,Outpatient,,,1452,1016.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,880.38,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,1342.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,671.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,905.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.07,1342.14,
DEBRID SKIN SBQ TISS MUSC BO <,550480,CDM,975,RC,11044,HCPCS,Outpatient,,,460,322,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,427.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,213.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,213.92,427.84,
LARINGOSCPY FOR ASPIRATION,550484,CDM,975,RC,31515,HCPCS,Outpatient,,,316,221.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,97.28,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,208.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.29,208.58,
INCISION BREAST LESION,550487,CDM,975,RC,19020,HCPCS,Outpatient,,,611,427.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,742.37,Other,Not Seperately Reimbusable,,,,48.4,Other,Not Seperately Reimbusable,587.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,293.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.75,587.5,
CYSTOURETHROSCOPY W FULGURAT,550490,CDM,975,RC,52214,HCPCS,Outpatient,,,384,268.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,330.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.29,330.58,
CMPLX RPR LID NS EAR LIP 1.1 2,550492,CDM,975,RC,13151,HCPCS,Outpatient,,,553,387.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,518.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,259.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,259.19,518.38,
INCIS EXTRAPARENCHYMAL LESN TE,550494,CDM,975,RC,54512,HCPCS,Outpatient,,,1077,753.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,1019.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,509.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,687.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509.52,1019.04,
REPR INIT ING HERNIA > 5YRS,550500,CDM,975,RC,49505,HCPCS,Outpatient,,,1015,710.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.38,Other,Not Seperately Reimbusable,,,,2.4,Other,Not Seperately Reimbusable,994.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,497.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,671.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,497.41,994.82,
EPIDIDYMECTOMY UNILATERAL,550504,CDM,975,RC,54860,HCPCS,Outpatient,,,831,581.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,792.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,396.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,535.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.44,792.88,
EXC LES TEN OR JNT HND OR FIN,550506,CDM,975,RC,26160,HCPCS,Outpatient,,,609,426.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,595.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,297.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,402.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,297.86,595.72,
REPR INITIAL VENTRAL HERNIA IN,550509,CDM,975,RC,49561,HCPCS,Outpatient,,,1915,1340.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
REPR UMB HERNIA.5 YRS RED,550510,CDM,975,RC,49585,HCPCS,Outpatient,,,904,632.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
COLNSCPY FLEX SPLEN BX,550511,CDM,975,RC,45380,HCPCS,Outpatient,,,521,364.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.73,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,375.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,187.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.66,375.32,
DEBRID SKIN SBQ TISSUE<=20 SQ,550512,CDM,975,RC,11042,HCPCS,Outpatient,,,121,84.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,113.98,
AMPUTATION OF TOE; MTATRSL JOI,550513,CDM,975,RC,28820,HCPCS,Outpatient,,,772,540.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,20.4,Other,Not Seperately Reimbusable,339.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,169.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.59,339.18,
AMPUTATION OF LOWER LEG,550514,CDM,975,RC,27880,HCPCS,Outpatient,,,1731,1211.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,91.2,Other,Not Seperately Reimbusable,,,,25.2,Other,Not Seperately Reimbusable,1707.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,853.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1152.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,853.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,853.61,1707.22,
REPR INIT INCIS VENT HERNIA RE,550516,CDM,975,RC,49560,HCPCS,Outpatient,,,1515,1060.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
MESH IMPLANTATION OF VENTRAL H,550517,CDM,975,RC,49568,HCPCS,Outpatient,,,558,390.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
DEBRID SBQ MUSC FASCIA<=20CM,550519,CDM,975,RC,11043,HCPCS,Outpatient,,,312,218.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,190.8,Other,Not Seperately Reimbusable,290.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,145.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.16,290.32,
AMPUTATN THIGH THRU FEMUR ANY,550521,CDM,975,RC,27590,HCPCS,Outpatient,,,1631,1141.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,127.07,Other,Not Seperately Reimbusable,,,,61.6,Other,Not Seperately Reimbusable,1491.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,745.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1007.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,745.98,1491.96,
EGD DILAT STRICTURE,550522,CDM,975,RC,43245,HCPCS,Outpatient,,,501,350.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,44.99,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,329.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,164.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.54,329.08,
EXC B9 LESN MRGN XCP SK TG T/A,550524,CDM,975,RC,11406,HCPCS,Outpatient,,,488,341.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,27.2,Other,Not Seperately Reimbusable,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,233.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.21,466.42,
EXCSN GANGLION WRIST PRIMARY,550527,CDM,975,RC,25111,HCPCS,Outpatient,,,621,434.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,18.4,Other,Not Seperately Reimbusable,612.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,306.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,413.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,306.25,612.5,
PRP I/HERN INIT BLOCK > 5YEAR,550529,CDM,975,RC,49507,HCPCS,Outpatient,,,1198,838.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,1119,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,559.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,755.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,559.5,1119,
CYSTOURETHRO W/ INITIAL IMPLAN,550531,CDM,975,RC,52441,HCPCS,Outpatient,,,424,296.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,44.38,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,394.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,197.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,266.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,197.32,394.64,
CYSTOURETHRO EACH ADDITONL IMP,550532,CDM,975,RC,52442,HCPCS,Outpatient,,,144,100.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,95.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,64.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.8,95.6,
PRTL EXCIS BONEFT NOT TALUS OR,550536,CDM,975,RC,28122,HCPCS,Outpatient,,,828,579.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,51.6,Other,Not Seperately Reimbusable,829.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,414.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,560.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,414.82,829.64,
EXC FACE-MM B9+MARG 0.6-1 CM,550537,CDM,975,RC,11441,HCPCS,Outpatient,,,203,142.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,246.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,123.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.18,246.36,
CHOLECYSTECTOMY,550539,CDM,975,RC,47600,HCPCS,Outpatient,,,2200,1540,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,2037.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,1018.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1375,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1018.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1018.52,2037.04,
INCIS REMOV FB SUBQ COMP,550540,CDM,975,RC,10121,HCPCS,Outpatient,,,366,256.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,124.64,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,344.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,172.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,232.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.23,344.46,
INCIS ISCHIO ABSCESS PROFEE,550542,CDM,975,RC,46040,HCPCS,Outpatient,,,1206,844.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,40.8,Other,Not Seperately Reimbusable,797.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,398.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.54,797.08,
EGD REMOVAL OF FOREIGN BODY,550544,CDM,975,RC,43247,HCPCS,Outpatient,,,425,297.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,32.8,Other,Not Seperately Reimbusable,330.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,223.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165.38,330.76,
DEB SUBQ TISSUE ADD-ON,550545,CDM,975,RC,11045,HCPCS,Outpatient,,,52,36.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,116,Other,Not Seperately Reimbusable,48.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.09,48.18,
SIGMOIDOSCOPY WITH POLYPECTOMY,550546,CDM,975,RC,45333,HCPCS,Outpatient,,,369,258.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.9,Other,Not Seperately Reimbusable,,,,220,Other,Not Seperately Reimbusable,176.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,88.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.25,176.5,
CYSTO CHEMODENERVATION,550548,CDM,975,RC,52287,HCPCS,Outpatient,,,322,225.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.3,Other,Not Seperately Reimbusable,,,,220,Other,Not Seperately Reimbusable,318.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,159.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.27,318.54,
"AMPUTATION, METATARSAL, W/ TOE",550550,CDM,975,RC,28810,HCPCS,Outpatient,,,808,565.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.55,Other,Not Seperately Reimbusable,,,,56,Other,Not Seperately Reimbusable,798.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,399.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.24,798.48,
OSTECTOMY COMPLETE 1ST METATAR,550551,CDM,975,RC,28111,HCPCS,Outpatient,,,624,436.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,131.2,Other,Not Seperately Reimbusable,603.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,301.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,407.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.8,603.6,
EXC FOOS/TOE TUM SC 1.5CM>,550552,CDM,975,RC,28039,HCPCS,Outpatient,,,681,476.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,86.94,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,640.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,320.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,432.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,320.29,640.58,
AMPUTAT TOE MTATRSL PHLNGL,550554,CDM,975,RC,28820,HCPCS,Outpatient,,,772,540.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,55.94,Other,Not Seperately Reimbusable,,,,51.6,Other,Not Seperately Reimbusable,339.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,169.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.59,339.18,
SESAMOIDECTOMY 1ST TOE,550555,CDM,975,RC,28315,HCPCS,Outpatient,,,639,447.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,615.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,307.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,415.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,307.64,615.28,
EXC FACE-MM B9+MARG 1.1-2 CM,550557,CDM,975,RC,11442,HCPCS,Outpatient,,,268,187.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,91.2,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,272.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,136.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.18,272.36,
EXC FACE BENIGN 3.1-4 CM,550558,CDM,975,RC,11444,HCPCS,Outpatient,,,443,310.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,121.2,Other,Not Seperately Reimbusable,421.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,210.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,284.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.8,421.6,
LAPAROSCOPIC CHOLECYSTECTOMY,550559,CDM,975,RC,47562,HCPCS,Outpatient,,,1350,945,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,11.6,Other,Not Seperately Reimbusable,1257.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,628.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,848.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,628.83,1257.66,
DESTR LES VULVA EXT,550568,CDM,975,RC,56515,HCPCS,Outpatient,,,400,280,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,24.4,Other,Not Seperately Reimbusable,400.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,200.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.3,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.22,400.44,
BIOPSY OF LIVER WEDGE,550575,CDM,975,RC,47100,HCPCS,Outpatient,,,1724,1206.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,10.4,Other,Not Seperately Reimbusable,1609.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,804.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1086.16,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,804.56,1609.12,
EXCIS TUM THIGH KNEE SUBCU,550578,CDM,975,RC,27327,HCPCS,Outpatient,,,616,431.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48.64,Other,Not Seperately Reimbusable,,,,33.2,Other,Not Seperately Reimbusable,593.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,296.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,296.99,593.98,
EXCIS BEN LES FACE 2.1 3.0 CM,550582,CDM,975,RC,11443,HCPCS,Outpatient,,,344,240.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,333.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,166.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.92,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.61,333.22,
CMPLX RPR FACE NCK GEN HND FT,550584,CDM,975,RC,13131,HCPCS,Outpatient,,,481,336.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,450.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,225.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.43,450.86,
EXC B9 LESN MRGN XCP SK TG T/A,550586,CDM,975,RC,11403,HCPCS,Outpatient,,,412,288.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,277.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,138.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.53,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.91,277.82,
EXC B9 LESN MRGN XCP SK TG T/A,550588,CDM,975,RC,11404,HCPCS,Outpatient,,,458,320.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,127.6,Other,Not Seperately Reimbusable,306.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,153.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.35,306.7,
IRR IMP VEN ACC DEV DRUG DELIV,550615,CDM,975,RC,96523,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.97,Other,Not Seperately Reimbusable,,,,59.6,Other,Not Seperately Reimbusable,43.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.67,43.34,
I & D PILON CYST COMP,550619,CDM,975,RC,10081,HCPCS,Outpatient,,,338,236.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,290.02,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,321.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,160.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.79,321.58,
CLOSE SECDRY WND COMP OR EXT,550622,CDM,975,RC,13160,HCPCS,Outpatient,,,1587,1110.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,1495.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,747.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1009.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,747.54,1495.08,
ABDMNL PARCENTESIS W IMAG GUID,550624,CDM,975,RC,49083,HCPCS,Outpatient,,,215,150.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,41.34,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,198.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,99.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.36,198.72,
DRAIN FINGER ABSCESS COMP,550627,CDM,975,RC,26011,HCPCS,Outpatient,,,361,252.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,27.97,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,346.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,173.06,346.12,
FASCIOTOMY FT AND/OR TOE,550632,CDM,975,RC,28008,HCPCS,Outpatient,,,578,404.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2.8,Other,Not Seperately Reimbusable,555.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,277.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,375.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.88,555.76,
CYSTO WCATH W BRSH BX URETR&OR,550638,CDM,975,RC,52007,HCPCS,Outpatient,,,347,242.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,10,Other,Not Seperately Reimbusable,312.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,156.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,211.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,156.34,312.68,
REMOVAL OF SKIN TAGS UP TO 15,550641,CDM,975,RC,11200,HCPCS,Outpatient,,,140,98,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,210.37,Other,Not Seperately Reimbusable,,,,0.4,Other,Not Seperately Reimbusable,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.24,140.48,
EXCIS TUM SFT TISS NECK THOR,550647,CDM,975,RC,21555,HCPCS,Outpatient,,,793,555.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,577.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,288.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.81,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.75,577.5,
INSERT TUN CENT CATH VEN DEVIC,550649,CDM,975,RC,36561,HCPCS,Outpatient,,,680,476,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,176.32,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,622.7,
CLOSURE OF GASTROSTOMY SURGICA,550651,CDM,975,RC,43870,HCPCS,Outpatient,,,1859,1301.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,1348.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,674.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,910.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,674.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,674.33,1348.66,
URETHROMETOPLSTY W/PRTL EXC DS,550653,CDM,975,RC,53460,HCPCS,Outpatient,,,1208,845.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,80.26,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,866.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,433.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,585.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,433.46,866.92,
EXC FOREARM LES SC 3 CM/>,550655,CDM,975,RC,25071,HCPCS,Outpatient,,,450,315,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,199.42,Other,Not Seperately Reimbusable,,,,12.4,Other,Not Seperately Reimbusable,803.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,401.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,542.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.74,803.48,
RPR AA HRN 1ST < 3CM RDC,550657,CDM,975,RC,49591,HCPCS,Outpatient,,,362,253.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.69,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,653.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,326.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,441.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.76,653.52,
EXC FACE-MM B9+MARG 0.5 CM/<,550659,CDM,975,RC,11440,HCPCS,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,195.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.99,195.98,
DESTRUCT B9 LESION 1-14,550661,CDM,975,RC,17110,HCPCS,Outpatient,,,118,82.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4.4,Other,Not Seperately Reimbusable,125.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.74,125.48,
DRAINAGE OF SCROTUM,550663,CDM,975,RC,54700,HCPCS,Outpatient,,,225,157.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,17.63,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,402.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,201.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,201.37,402.74,
REVISE SPERMATIC CORD VEINS,550889,CDM,975,RC,55530,HCPCS,Outpatient,,,780,546,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,64.8,Other,Not Seperately Reimbusable,666.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,333.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,449.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.16,666.32,
REMOVE DRUG IMPLANT DEVICE,550891,CDM,975,RC,11982,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,32.4,Other,Not Seperately Reimbusable,139.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,69.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.54,139.08,
ADHESIOLYSIS TUBE OVARY,550894,CDM,975,RC,58740,HCPCS,Outpatient,,,972,680.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.09,Other,Not Seperately Reimbusable,,,,26,Other,Not Seperately Reimbusable,1716.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,858.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1158.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,858.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,858.21,1716.42,
INC&RMVL FB SUBQ TISS SMPL,550896,CDM,975,RC,10120,HCPCS,Outpatient,,,161,112.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.81,Other,Not Seperately Reimbusable,,,,144,Other,Not Seperately Reimbusable,195.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.51,195.02,
CHANGE OF BLADDER TUBE,550898,CDM,975,RC,51705,HCPCS,Outpatient,,,104,72.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.71,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,97.34,
EXC SHOULDER TUM DEEP < 5 CM,550900,CDM,975,RC,23076,HCPCS,Outpatient,,,450,315,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.81,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,900,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,450,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,900,
I&D OF VULVA/PERINEUM,550902,CDM,975,RC,56405,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.81,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,236.06,
INSERT TEMP BLADDER CATH,550903,CDM,975,RC,51702,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.81,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,48.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.02,48.04,
EXC FACE TUM DEEP < 2 CM,550905,CDM,975,RC,21013,HCPCS,Outpatient,,,570,399,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,754.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,377.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,509.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,377.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,377.1,754.2,
REVISION OF PENIS,550907,CDM,975,RC,54300,HCPCS,Outpatient,,,691,483.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,1220.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,610.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,823.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.24,1220.48,
EXC TR-EXT MAL+MARG 1.1-2 CM,550911,CDM,975,RC,11602,HCPCS,Outpatient,,,260,182,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,299.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.72,299.44,
INTMD RPR S/A/T/EXT 2.5 CM/<,550913,CDM,975,RC,12031,HCPCS,Outpatient,,,278,194.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,277.2,Other,Not Seperately Reimbusable,280.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,140.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.16,280.32,
PARTIAL REMOVAL OF PENIS,550915,CDM,975,RC,54120,HCPCS,Outpatient,,,678,474.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,58.98,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1197.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,598.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,808.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,598.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,598.98,1197.96,
EXCISION OF SCROTUM,551506,CDM,975,RC,55150,HCPCS,Outpatient,,,450,315,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,170.85,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,900,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,450,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,607.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450,900,
APPENDECTOMY,741062,CDM,975,RC,44950,HCPCS,Outpatient,,,827,578.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1668.96,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1224.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,612.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,826.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,612.17,1224.34,
REP COMP TRUNK 2.6 TO 7.5CM,743854,CDM,975,RC,13101,HCPCS,Outpatient,,,694,485.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,90.59,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,456.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,308.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.48,456.96,
PARTL REMOVAL OF FT BONE,893390,CDM,975,RC,28288,HCPCS,Outpatient,,,842,589.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,817,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,408.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,551.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.5,817,
EXC TAGS MULTI PAPILLAE,893393,CDM,975,RC,46230,HCPCS,Outpatient,,,346,242.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,68,Other,Not Seperately Reimbusable,327.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,163.92,327.84,
CRPRA CVRNOSA/SPNGSM SHUNT,893395,CDM,975,RC,54430,HCPCS,Outpatient,,,1275,892.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,1208.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,604.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,815.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,604.36,1208.72,
INSERT TUN CENT CATH VEN DEVIC,893398,CDM,975,RC,36561,HCPCS,Outpatient,,,867,606.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,622.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,420.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,311.35,622.7,
EXC HYPRPLSTC ALVELR MUCSA EA,893405,CDM,975,RC,41828,HCPCS,Outpatient,,,627,438.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,415.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,207.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,207.92,415.84,
SIGMOIDOSCPY FLX W/BIOPSY SING,893407,CDM,975,RC,45331,HCPCS,Outpatient,,,202,141.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,38.3,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,134.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,67.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,90.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.4,134.8,
EXCISN OF VAGINAL CYST OR TUMO,893409,CDM,975,RC,57135,HCPCS,Outpatient,,,535,374.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.26,Other,Not Seperately Reimbusable,,,,63.6,Other,Not Seperately Reimbusable,354.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,177.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.05,354.1,
ENUCLEATN EXT THROMB HEMORR,893414,CDM,975,RC,46320,HCPCS,Outpatient,,,322,225.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,213.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,106.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.88,213.76,
EGD BALLOON DILATION <30MM,893423,CDM,975,RC,43249,HCPCS,Outpatient,,,437,305.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.61,Other,Not Seperately Reimbusable,,,,54.4,Other,Not Seperately Reimbusable,287.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,143.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.91,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.64,287.28,
CLNSC FLEXIBLE W CONTROL BLEED,893425,CDM,975,RC,45382,HCPCS,Outpatient,,,742,519.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,26.14,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,483.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,241.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,241.86,483.72,
HEMORRHOID NTRNL XTRNL 1 COLUM,893427,CDM,975,RC,46257,HCPCS,Outpatient,,,1182,827.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,34.8,Other,Not Seperately Reimbusable,779.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,389.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,526.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,389.73,779.46,
TRURL RESJ RESIDUAL/REGROWTH O,893429,CDM,975,RC,52630,HCPCS,Outpatient,,,1148,803.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,21.2,Other,Not Seperately Reimbusable,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,765.22,
BIOPSY OF URETHRA,893431,CDM,975,RC,53200,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.18,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,268.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.44,268.88,
DESTRJN LES PENIS SURG EXC SIM,893433,CDM,975,RC,54060,HCPCS,Outpatient,,,369,258.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.58,Other,Not Seperately Reimbusable,,,,62.8,Other,Not Seperately Reimbusable,247.44,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,123.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.72,247.44,
URETHRLYS TRANSVAG W SCOPE,893435,CDM,975,RC,53500,HCPCS,Outpatient,,,2141,1498.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,29.18,Other,Not Seperately Reimbusable,,,,95.6,Other,Not Seperately Reimbusable,1418.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,709.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,957.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.32,1418.64,
LARYNGOSCOPY W/WO TRACHEOSCOPY,893518,CDM,975,RC,31515,HCPCS,Outpatient,,,316,221.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,208.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,104.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.29,208.58,
AMPUTATION LEG AT THIGH,893519,CDM,975,RC,27590,HCPCS,Outpatient,,,641,448.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2.8,Other,Not Seperately Reimbusable,1282,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,641,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,865.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,641,1282,
ASPIR HYDROCELE TUNICA VAGIS W,893524,CDM,975,RC,55000,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,1.2,Other,Not Seperately Reimbusable,159.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,79.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.65,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,79.74,159.48,
COLONOSCOPY DIAGNOSTIC,893526,CDM,975,RC,45378,HCPCS,Outpatient,,,641,448.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.65,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,345.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.74,345.48,
SCROTOPLASTY SIMPLE,893529,CDM,975,RC,55175,HCPCS,Outpatient,,,691,483.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,49.25,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,689.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,344.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,465.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,344.91,689.82,
EXC FOOT/TOE TUM SC < 1.5CM,893532,CDM,975,RC,28043,HCPCS,Outpatient,,,490,343,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,39.52,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,492.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,246.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,332.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,246.25,492.5,
PARTIAL REMOVAL FOOT FASCIA,893535,CDM,975,RC,28060,HCPCS,Outpatient,,,681,476.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,218.88,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,679.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,339.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,458.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,339.81,679.62,
REPAIR ING HERNIA SLIDING,893537,CDM,975,RC,49525,HCPCS,Outpatient,,,1101,770.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,1092.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,546.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,737.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,546.3,1092.6,
INCISION THROMBOSED HEMORRHOID,893539,CDM,975,RC,46083,HCPCS,Outpatient,,,207,144.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,13.38,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,206.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.05,206.1,
HEMORRHOIDECTOMY NTRNL XTRNL 1,893541,CDM,975,RC,46255,HCPCS,Outpatient,,,678,474.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,666.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,333.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.04,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,333.36,666.72,
TRACHEOSTOMY EMERGENCY PROC TR,893544,CDM,975,RC,31603,HCPCS,Outpatient,,,618,432.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.26,Other,Not Seperately Reimbusable,,,,136,Other,Not Seperately Reimbusable,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,608.74,
UNLISTD LAPAROSCOPIC PROC LIVE,893546,CDM,975,RC,47379,HCPCS,Outpatient,,,1493,1045.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SIGMOIDOSCOPY FLX W RMVL FOREI,893552,CDM,975,RC,45332,HCPCS,Outpatient,,,199,139.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,9.2,Other,Not Seperately Reimbusable,197.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,197.34,
SIGMOIDOSCOPY FLX W RMVL FOREI,893553,CDM,975,RC,45332,HCPCS,Outpatient,,,199,139.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.62,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,197.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,133.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.67,197.34,
IRRIGATION CORPORA CAVERNOSA P,893555,CDM,975,RC,54220,HCPCS,Outpatient,,,254,177.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,14.8,Other,Not Seperately Reimbusable,255.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,127.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,172.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.83,255.66,
ENDOSCOPIC INJECTION/IMPLANT P,893560,CDM,975,RC,51715,HCPCS,Outpatient,,,247,172.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,377.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,188.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.73,377.46,
INJECTION PEYRONIW DISEASE,893564,CDM,975,RC,54200,HCPCS,Outpatient,,,159,111.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,162.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,81.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,81.23,162.46,
DIAG LAPARO SEPARATE PROC,893567,CDM,975,RC,49320,HCPCS,Outpatient,,,628,439.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,626.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,313.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,422.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,313.01,626.02,
CIRCUMCISION W/CLAMP/OTH DEV W,893573,CDM,975,RC,54150,HCPCS,Outpatient,,,194,135.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,35.87,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,182.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.32,182.64,
EXC B9 LESN MRGN XCP SK TG S/N,893580,CDM,975,RC,11426,HCPCS,Outpatient,,,496,347.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,37.7,Other,Not Seperately Reimbusable,,,,642.4,Other,Not Seperately Reimbusable,504.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,340.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,252.07,504.14,
EGD DIAGNOSTIC BRUSH WASH,893582,CDM,975,RC,43235,HCPCS,Outpatient,,,224,156.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,426.82,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,229.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,114.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,154.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114.6,229.2,
AMPUTATION TOE & METATARSAL,893584,CDM,975,RC,28810,HCPCS,Outpatient,,,455,318.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,57.15,Other,Not Seperately Reimbusable,,,,494,Other,Not Seperately Reimbusable,798.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,399.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,399.24,798.48,
EXCISION B9 TUMO/CYST MANDIBLE,893587,CDM,975,RC,21040,HCPCS,Outpatient,,,663,464.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2511.04,Other,Not Seperately Reimbusable,,,,0.8,Other,Not Seperately Reimbusable,671.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,335.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,453.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,335.98,671.96,
TEST,893590,CDM,975,RC,10080,HCPCS,Outpatient,,,441,308.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,722.4,Other,Not Seperately Reimbusable,194.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,194.84,
INCISION AND DRAINAGE PILONIDA,893591,CDM,975,RC,10080,HCPCS,Outpatient,,,441,308.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.32,Other,Not Seperately Reimbusable,,,,18.8,Other,Not Seperately Reimbusable,194.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,194.84,
EXC MAL LESION TRUNK/ARM/LEG 0,893593,CDM,975,RC,11601,HCPCS,Outpatient,,,270,189,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,11.2,Other,Not Seperately Reimbusable,275.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,137.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,186.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137.91,275.82,
EXC HAND LES SC 1.5 CM/>,893596,CDM,975,RC,26111,HCPCS,Outpatient,,,766,536.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,785.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.88,785.76,
REMOVAL RECTAL OBSTRUCTION,893598,CDM,975,RC,45915,HCPCS,Outpatient,,,4,2.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,103.36,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,5.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,4,8,
EXCIS SFT TUM BACK FLANK SUBFA,893600,CDM,975,RC,21932,HCPCS,Outpatient,,,1355,948.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.82,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,1255.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,627.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,847.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,627.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,627.61,1255.22,
EXC MAL LES FACE/EAR/EYE/NS/LP,893607,CDM,975,RC,11646,HCPCS,Outpatient,,,738,516.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.9,Other,Not Seperately Reimbusable,,,,90,Other,Not Seperately Reimbusable,730.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,365.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,492.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,365.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,365.14,730.28,
FULL THCK HEAD HND 20 SQ CM,893609,CDM,975,RC,15240,HCPCS,Outpatient,,,1475,1032.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,275.6,Other,Not Seperately Reimbusable,1476.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,738.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,996.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738.33,1476.66,
REMOVE FECAL MATTER FB ANES,893614,CDM,975,RC,45915,HCPCS,Outpatient,,,414,289.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,428.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,214.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.28,428.56,
RPR AA HRN 1ST < 3 MCR/STRN,893615,CDM,975,RC,49592,HCPCS,Outpatient,,,854,597.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,52.9,Other,Not Seperately Reimbusable,,,,7.6,Other,Not Seperately Reimbusable,910.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,455.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,614.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,455.03,910.06,
ALVEOLOPLSTY EA QUADRNT SPECIF,893620,CDM,975,RC,41874,HCPCS,Outpatient,,,441,308.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,138.4,Other,Not Seperately Reimbusable,452.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,226.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,305.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.19,452.38,
CYSTO W FULG AND OR RESECT BLA,893622,CDM,975,RC,52235,HCPCS,Outpatient,,,571,399.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.77,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,542.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,271.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,271.43,542.86,
CYSTO W TRT URETEROPELVIC JU,893623,CDM,975,RC,52342,HCPCS,Outpatient,,,610,427,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,41.34,Other,Not Seperately Reimbusable,,,,104.8,Other,Not Seperately Reimbusable,581.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,290.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.84,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,290.99,581.98,
FULL THCK HEAD HND 20 SQ CM,893624,CDM,975,RC,15240,HCPCS,Outpatient,,,1603,1122.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1476.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,738.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,996.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,738.33,1476.66,
CYSTO URETERO PELVIC STRICTURE,893638,CDM,975,RC,52345,HCPCS,Outpatient,,,779,545.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,52.9,Other,Not Seperately Reimbusable,,,,6.8,Other,Not Seperately Reimbusable,742.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,371.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,501.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.25,742.5,
PAPILLECTOMY SGL TAG ANUS,893640,CDM,975,RC,46220,HCPCS,Outpatient,,,247,172.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.22,Other,Not Seperately Reimbusable,,,,17.2,Other,Not Seperately Reimbusable,227.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,113.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,153.81,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.93,227.86,
RAINAGE OF EYELID ABSCESS,893650,CDM,975,RC,67700,HCPCS,Outpatient,,,232,162.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,58.37,Other,Not Seperately Reimbusable,,,,7.6,Other,Not Seperately Reimbusable,212.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,106.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.21,212.42,
I & D BART GL& ABSCESS,893651,CDM,975,RC,56420,HCPCS,Outpatient,,,227,158.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,145.31,Other,Not Seperately Reimbusable,,,,91.6,Other,Not Seperately Reimbusable,206.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.46,206.92,
RPR ENTEROCELE VAG APPRCH SEP,893652,CDM,975,RC,57268,HCPCS,Outpatient,,,1033,723.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,48.64,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,957,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,478.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,645.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,478.5,957,
NJX PX NFROSGRM &/URTRGRM,893653,CDM,975,RC,50431,HCPCS,Outpatient,,,660,462,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,12.16,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,122.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.38,122.76,
EXC LES SPERMATIC CORD SEP PRO,893658,CDM,975,RC,55520,HCPCS,Outpatient,,,933,653.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,9.12,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,868.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,434.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,586.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,434.34,868.68,
INSJ MESH PROSTH PLVC FLR DFCT,893659,CDM,975,RC,57267,HCPCS,Outpatient,,,505,353.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,93.63,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,478.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,239.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,322.76,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,239.08,478.16,
EPIDIDYMECTOMY BILATERAL,893666,CDM,975,RC,54861,HCPCS,Outpatient,,,1073,751.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,1076.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,538.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,726.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.21,1076.42,
CLSD TX CLAVICULAR FX W/O MANI,893669,CDM,975,RC,23500,HCPCS,Outpatient,,,432,302.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,6.08,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,434.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,217.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.36,434.72,
REVISION OF PENIS,893673,CDM,975,RC,54435,HCPCS,Outpatient,,,781,546.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,783.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,391.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,528.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,391.66,783.32,
EXC TUM FACE SCLP SFT TISS <=2,893677,CDM,975,RC,21014,HCPCS,Outpatient,,,983,688.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,,,,5.6,Other,Not Seperately Reimbusable,979.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,489.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,661.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,489.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,489.84,979.68,
EXC FACE LES SBQ 2 CM/>,893681,CDM,975,RC,21012,HCPCS,Outpatient,,,560,392,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,217.06,Other,Not Seperately Reimbusable,,,,152,Other,Not Seperately Reimbusable,637.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,318.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,430.11,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,318.6,637.2,
EXC THIGH/KNEE LES SC 3CM/>,893683,CDM,975,RC,27337,HCPCS,Outpatient,,,650,455,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,316.4,Other,Not Seperately Reimbusable,794.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,397.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,536.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.3,794.6,
EXC SHOULDER LES SC 3 CM/>,893685,CDM,975,RC,23071,HCPCS,Outpatient,,,700,490,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,112.4,Other,Not Seperately Reimbusable,795.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,397.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,537.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,397.88,795.76,
LAP ING HERNIA REPAIR INIT,893687,CDM,975,RC,49650,HCPCS,Outpatient,,,550,385,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,36,Other,Not Seperately Reimbusable,822.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,411.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,555.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,411.16,822.32,
EXT ECG>7D<15D REV&INTERPJ,840495,CDM,976,RC,93248,HCPCS,Outpatient,,,72,50.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,46.21,Other,Not Seperately Reimbusable,,,,9.6,Other,Not Seperately Reimbusable,48.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,24.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,32.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.1,48.2,
EXT ECG>48HR<7D REV&INTERPJ,840497,CDM,976,RC,93244,HCPCS,Outpatient,,,66,46.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,54.72,Other,Not Seperately Reimbusable,,,,8.4,Other,Not Seperately Reimbusable,43.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,21.86,43.72,
ECG MONITOR REVIEW24 HRS,850493,CDM,976,RC,93227,HCPCS,Outpatient,,,51,35.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,1.22,Other,Not Seperately Reimbusable,,,,2,Other,Not Seperately Reimbusable,34.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,34.6,
EXTERNAL ECG 1-30 DAYS INTERP,850494,CDM,976,RC,93228,HCPCS,Outpatient,,,71,49.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.28,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,47.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,47.04,
HOLTER MONITOR REV/INT 24 HR,850460,CDM,976,RC,93227,HCPCS,Outpatient,,,64,44.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.3,34.6,
HOLTER MONITOR REV/INT 3-14 DA,850475,CDM,976,RC,93228,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,23.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,31.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.52,47.04,
REMOVE FB CORN WO SLIT,201393,CDM,981,RC,65220,HCPCS,Outpatient,,,82,57.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,100.64,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,77.68,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,38.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,52.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,38.84,77.68,
SMPL RPR SCP-NCK-GN-TRNK-XTRM,201395,CDM,981,RC,12006,HCPCS,Outpatient,,,319,223.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,153.82,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,223.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,111.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.13,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,111.95,223.9,
TUBE THORACOSTOMY,201398,CDM,981,RC,32551,HCPCS,Outpatient,,,453,317.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,198.82,Other,Not Seperately Reimbusable,,,,32.4,Other,Not Seperately Reimbusable,295.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,147.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.54,295.08,
I&D VULVA PERINEAL ABS,201401,CDM,981,RC,56405,HCPCS,Outpatient,,,249,174.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,71.81,Other,Not Seperately Reimbusable,,,,22.8,Other,Not Seperately Reimbusable,236.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,159.34,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,118.03,236.06,
CLTX DISTL FIB FX W MAN,201477,CDM,981,RC,27788,HCPCS,Outpatient,,,1128,789.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,143.62,Other,Not Seperately Reimbusable,,,,121.2,Other,Not Seperately Reimbusable,733.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,366.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,495.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366.95,733.9,
CLTX FX PHALANX WO MAN,201519,CDM,981,RC,28510,HCPCS,Outpatient,,,225,157.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.83,Other,Not Seperately Reimbusable,,,,15.2,Other,Not Seperately Reimbusable,226.5,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,113.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.25,226.5,
NEEDLE PLACE INTRAOSS INFUSE,201621,CDM,981,RC,36680,HCPCS,Outpatient,,,144,100.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,22.3,Other,Not Seperately Reimbusable,,,,23.2,Other,Not Seperately Reimbusable,114.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.08,114.16,
CARDIOVERSION EXTERNAL,201623,CDM,981,RC,92960,HCPCS,Outpatient,,,243,170.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,23.39,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,201.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,100.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,100.89,201.78,
INJ ANSTH TRIGEMINAL NERVE,201648,CDM,981,RC,64400,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,13.2,Other,Not Seperately Reimbusable,97.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.64,97.28,
INJ ANSTH OTH PERIPHERAL NERVE,201654,CDM,981,RC,64450,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,10.34,Other,Not Seperately Reimbusable,,,,642.4,Other,Not Seperately Reimbusable,79.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.6,79.2,
MOD SED SAME PHYS/QHP 5/>YRS,550643,CDM,981,RC,99152,HCPCS,Outpatient,,,24,16.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,354.69,Other,Not Seperately Reimbusable,,,,91.6,Other,Not Seperately Reimbusable,23.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.58,23.16,
MOD SED SAME PHYS/QHP EA,550645,CDM,981,RC,99153,HCPCS,Outpatient,,,19,13.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,43.52,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,20.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,13.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.08,20.16,
I&D PILON CYST SIMP,741750,CDM,981,RC,10080,HCPCS,Outpatient,,,441,308.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.1,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,194.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.42,194.84,
REP SMP FACE 12.6 TO 20.0CM,743902,CDM,981,RC,12016,HCPCS,Outpatient,,,503,352.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.76,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,247.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,123.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.58,247.16,
DRAINAGE OF ABSCESS OF PALATE,893397,CDM,981,RC,42000,HCPCS,Outpatient,,,301,210.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,7.07,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,202.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,101.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.38,202.76,
INCIS ISCHIO ABSCESS PROFEE,893403,CDM,981,RC,46040,HCPCS,Outpatient,,,1206,844.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.55,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,797.08,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,398.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,538.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,398.54,797.08,
INJ TRIGGER POINT 1 TO 2 MUSCL,893436,CDM,981,RC,20552,HCPCS,Outpatient,,,108,75.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.55,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,69.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.85,69.7,
CLTX DSTL RDL FX/EPIPHYSL SEP,893438,CDM,981,RC,25605,HCPCS,Outpatient,,,145,101.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.13,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,290,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,145,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145,290,
THORAC NDL CATH ASPN PLRL SPS,893494,CDM,981,RC,32554,HCPCS,Outpatient,,,259,181.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,46.24,Other,Not Seperately Reimbusable,,,,972.4,Other,Not Seperately Reimbusable,167.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.36,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.97,167.94,
DEBRIDEMENT OPEN WOUND 20 SQ C,893498,CDM,981,RC,97597,HCPCS,Outpatient,,,105,73.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.7,Other,Not Seperately Reimbusable,,,,28.4,Other,Not Seperately Reimbusable,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,67.72,
RPR INTERMED F/E/E/N/L&/MUC 7.,893521,CDM,981,RC,12054,HCPCS,Outpatient,,,619,433.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,51.68,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,413.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,206.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,279.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.85,413.7,
DRAINAGE OF CUM LESION,893562,CDM,981,RC,41800,HCPCS,Outpatient,,,421,294.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,45.15,Other,Not Seperately Reimbusable,,,,16.8,Other,Not Seperately Reimbusable,280.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,140.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.05,280.1,
CLSD TX SHOULDER DISCLC W/MANI,893569,CDM,981,RC,23655,HCPCS,Outpatient,,,1156,809.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,31.55,Other,Not Seperately Reimbusable,,,,23.2,Other,Not Seperately Reimbusable,772.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,386.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,521.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.33,772.66,
CLD TRT DISLOC HIP REQ ANES,893602,CDM,981,RC,27252,HCPCS,Outpatient,,,1435,1004.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.44,Other,Not Seperately Reimbusable,,,,302.4,Other,Not Seperately Reimbusable,1419,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,709.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,957.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.5,1419,
CLSD TX CLAVICULAR FRACTURE W/,893611,CDM,981,RC,23500,HCPCS,Outpatient,,,425,297.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,20.67,Other,Not Seperately Reimbusable,,,,8.8,Other,Not Seperately Reimbusable,434.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,217.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,293.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,217.36,434.72,
I & D ABSCESS EAR SIMPLE,893629,CDM,981,RC,69000,HCPCS,Outpatient,,,231,161.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,34.82,Other,Not Seperately Reimbusable,,,,32,Other,Not Seperately Reimbusable,233.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,116.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.57,233.14,
MOD SED SAME PHYS/QHP <5 YRS,893631,CDM,981,RC,99151,HCPCS,Outpatient,,,48,33.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,21.76,Other,Not Seperately Reimbusable,,,,130,Other,Not Seperately Reimbusable,45.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,22.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.73,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.76,45.52,
REMOVE FB EYE CONJ SUPER,893634,CDM,981,RC,65205,HCPCS,Outpatient,,,55,38.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,32.64,Other,Not Seperately Reimbusable,,,,19.2,Other,Not Seperately Reimbusable,54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,54,
RPR LAC 2.5 CM/< PST ONE-THRD,893635,CDM,981,RC,41251,HCPCS,Outpatient,,,374,261.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,28.29,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,342.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,171.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.17,342.34,
DRSS DBRID BURN PRTL THCKNS LG,893643,CDM,981,RC,16030,HCPCS,Outpatient,,,265,185.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,35.9,Other,Not Seperately Reimbusable,,,,34,Other,Not Seperately Reimbusable,248.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.31,248.62,
CLTX PHAL FX WO MAN,893655,CDM,981,RC,26720,HCPCS,Outpatient,,,395,276.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,25.02,Other,Not Seperately Reimbusable,,,,17.2,Other,Not Seperately Reimbusable,360.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,180.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,243.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,180.3,360.6,
CLTX FX GREAT TOE WO MAN,893679,CDM,981,RC,28490,HCPCS,Outpatient,,,232,162.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,11.42,Other,Not Seperately Reimbusable,,,,22,Other,Not Seperately Reimbusable,233.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,116.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.76,233.52,
CHG OF CYSTOSTOMY TUBE,550075,CDM,981,RC,51705,HCPCS,Outpatient,,,116,81.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,54.8,Other,Not Seperately Reimbusable,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,97.34,
CYSTOSTOMY WITH DRAINAGE,550125,CDM,981,RC,51040,HCPCS,Outpatient,,,396,277.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,16.4,Other,Not Seperately Reimbusable,549.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,274.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,370.98,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.8,549.6,
URETHROLYSIS TRANSVAG W/SCOPE,550190,CDM,981,RC,53500,HCPCS,Outpatient,,,1100,770,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,16.42,Other,Not Seperately Reimbusable,,,,95.6,Other,Not Seperately Reimbusable,1418.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,709.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,957.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,709.32,1418.64,
NOVASURE ENDOMETRIAL ABLATION,550260,CDM,981,RC,58353,HCPCS,Outpatient,,,1674,1171.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,14.4,Other,Not Seperately Reimbusable,436.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,218.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,294.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,218.49,436.98,
TRURL RESCJ RESID/REGROW OBST,550350,CDM,981,RC,52630,HCPCS,Outpatient,,,1148,803.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,152.61,Other,Not Seperately Reimbusable,,,,6,Other,Not Seperately Reimbusable,765.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,516.52,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.61,765.22,
SIMPLE RPR F/E/E/N/L/M 12.6 TO,893516,CDM,981,RC,12016,HCPCS,Outpatient,,,503,352.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,8,Other,Not Seperately Reimbusable,247.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,123.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,166.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.58,247.16,
DEBRIDE TISSUE 1ST 20CM PHYS,9001,CDM,981,RC,11042,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,137.6,Other,Not Seperately Reimbusable,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,113.98,
DEBRIDE DEVITALIZED TISSUE PHY,9003,CDM,981,RC,97597,HCPCS,Outpatient,,,231,161.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,0.61,Other,Not Seperately Reimbusable,,,,644.8,Other,Not Seperately Reimbusable,67.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.86,67.72,
NEW PATIENT VS LEVEL 1 PHYS,9021,CDM,981,RC,99201,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
NEW PATIENT VS LEVEL 2 PHYS,9023,CDM,981,RC,99202,HCPCS,Outpatient,,,99,69.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,14,Other,Not Seperately Reimbusable,89.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,44.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.98,89.96,
NEW PATIENT VS LEVEL 3 PHYS,9025,CDM,981,RC,99203,HCPCS,Outpatient,,,140,98,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,16.4,Other,Not Seperately Reimbusable,155.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.89,155.78,
ESTABLISHED PT LEVEL 1,9031,CDM,981,RC,99211,HCPCS,Outpatient,,,22,15.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,1.6,Other,Not Seperately Reimbusable,16.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.31,16.62,
ESTABLISHED PT LEVEL 2,9033,CDM,981,RC,99212,HCPCS,Outpatient,,,50,35,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,30.8,Other,Not Seperately Reimbusable,67.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,45.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.53,67.06,
ESTABLISHED PT LEVEL 3,9035,CDM,981,RC,99213,HCPCS,Outpatient,,,83,58.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,14.8,Other,Not Seperately Reimbusable,125.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,62.52,125.04,
ESTABLISHED PT LEVEL 4,9037,CDM,981,RC,99214,HCPCS,Outpatient,,,117,81.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,30,Other,Not Seperately Reimbusable,184.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,92.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.18,184.36,
ESTABLISHED PT LEVEL 5,9039,CDM,981,RC,99215,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,3.04,Other,Not Seperately Reimbusable,,,,12.8,Other,Not Seperately Reimbusable,273.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,136.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.65,273.3,
DRSS DBRID BURN PRTL THCKNS LG,740350,CDM,981,RC,16030,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,220,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,110,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,148.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,110,220,
DRSS DBRID BURN PRTL THKNS MED,740400,CDM,981,RC,16025,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,202,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,101,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101,202,
DRSS DBRID PRTL THKNS BURN SM,740450,CDM,981,RC,16020,HCPCS,Outpatient,,,103,72.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,51.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.82,103.64,
INIT TRT 1ST DEGREE BURN,740500,CDM,981,RC,16000,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.6,87.2,
CHANGE OF CYSTOSTOMY TUBE SIMP,740509,CDM,981,RC,51705,HCPCS,Outpatient,,,98,68.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.7,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.67,97.34,
CAST APPLICATION LG.,740550,CDM,981,RC,Y7508,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAST APPLICATION SH.,740600,CDM,981,RC,Y7508,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAST REMOVAL LONG,740650,CDM,981,RC,Y7508,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAST REMOVAL SHORT,740700,CDM,981,RC,29705,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.05,84.1,
INTUBATION ENDOTRACHEAL EMERGE,740800,CDM,981,RC,31500,HCPCS,Outpatient,,,275,192.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.96,269.92,
ER VISIT E&M LOW MINOR,740900,CDM,981,RC,99281,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,22.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.86,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.01,22.02,
ER VISIT E&M LIMIT-MINOR SEVER,740950,CDM,981,RC,99284,HCPCS,Outpatient,,,239,167.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,116.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.62,233.24,
ER VISIT E&M MOD SEVER,741000,CDM,981,RC,99283,HCPCS,Outpatient,,,174,121.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,136.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,68.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.49,136.98,
ER VISIT E&M MOD SEVER LOW MOD,741050,CDM,981,RC,99282,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.27,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.2,80.4,
ER VISIT E&M HIGH SEVER SIGNIF,741052,CDM,981,RC,99285,HCPCS,Outpatient,,,349,244.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,338.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,228.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,169.07,338.14,
CRITCL CARE 1ST 30-74 MIN,741054,CDM,981,RC,99291,HCPCS,Outpatient,,,440,308,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,203.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.15,406.3,
CRITCL CARE EA ADD 30 MIN,741056,CDM,981,RC,99292,HCPCS,Outpatient,,,212,148.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,102.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.36,204.72,
EXC BEN LES TNK EXTRM LS 4.0CM,741070,CDM,981,RC,11406,HCPCS,Outpatient,,,641,448.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,466.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,233.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,233.21,466.42,
CLTX METCRPL DISLOC,741100,CDM,981,RC,26700,HCPCS,Outpatient,,,584,408.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,602.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,301.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,301.1,602.2,
NASAL/OROGASTRIC W/TUBE PLMT,741111,CDM,981,RC,43752,HCPCS,Outpatient,,,75,52.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.92,75.84,
REMOVE EXT HEM GROUPS 2+,741112,CDM,981,RC,46250,HCPCS,Outpatient,,,465,325.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,596.88,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,298.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,402.89,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,298.44,596.88,
REMOVE FB EAR WO ANES,741150,CDM,981,RC,69200,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,44.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,60.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.63,89.26,
REMOVE FB EYE CONJ SUPER,741200,CDM,981,RC,65205,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,36.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27,54,
REMOVE FB INTRANASAL,741250,CDM,981,RC,30300,HCPCS,Outpatient,,,221,154.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,224.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,112.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.09,224.18,
INCIS REMOV FB SUBQ SIMP,741300,CDM,981,RC,10120,HCPCS,Outpatient,,,193,135.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,195.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,97.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.51,195.02,
"GI INTUBATE, ASPIR W/WO LAVAGE",741350,CDM,981,RC,43753,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,20.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.96,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,20.71,41.42,
I&D LEG ANK DEEP  ABSCESS,741600,CDM,981,RC,27603,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
I&D ABSCESS SGL SIMP,741850,CDM,981,RC,10060,HCPCS,Outpatient,,,191,133.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,196.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,98.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.69,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.29,196.58,
INTRO NEEDLE INTRACATH VEIN,741950,CDM,981,RC,36000,HCPCS,Outpatient,,,37,25.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,8.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,11.66,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,8.64,17.28,
INTUBATION-PHY,741975,CDM,981,RC,31500,HCPCS,Outpatient,,,160,112,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.2,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,134.96,269.92,
CONTROL NASAL HEMORR ANT COMP,742250,CDM,981,RC,30903,HCPCS,Outpatient,,,150,105,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,147.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,73.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,99.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.98,147.96,
CONTROL NASAL HEMORR POST INIT,742300,CDM,981,RC,30905,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX SHOULDER DISLOC,742600,CDM,981,RC,23650,HCPCS,Outpatient,,,553,387.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,576.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,288.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,388.99,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,288.14,576.28,
SPINAL PUNCTURE LUMBAR DIAGNOS,742700,CDM,981,RC,62270,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,122.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,61.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,82.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.08,122.16,
APPLY LONG ARM SPLINT,742750,CDM,981,RC,29105,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.1,80.2,
SPLINT-ARM-LONG,742800,CDM,981,RC,29105,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,40.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.14,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.1,80.2,
APPLY SHORT ARM SPLINT STATIC,742850,CDM,981,RC,29125,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.57,75.14,
SPLINT-ARM-SHORT,742900,CDM,981,RC,29125,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,37.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.57,75.14,
APPLIC OF FINGER SPLINT STATIC,742950,CDM,981,RC,29130,HCPCS,Outpatient,,,56,39.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,55.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,27.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,37.21,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,27.56,55.12,
APPLY LONG LEG SPLINT,743000,CDM,981,RC,29505,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,97.74,
SPLINT-LEG-LONG,743050,CDM,981,RC,29505,HCPCS,Outpatient,,,101,70.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,48.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,65.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.87,97.74,
APPLY SHORT LEG SPLINT,743100,CDM,981,RC,29515,HCPCS,Outpatient,,,92,64.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,93.46,
SPLINT-LEG-SHORT,743150,CDM,981,RC,29515,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,93.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.09,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,46.73,93.46,
STRAPPING ELBOW OR WRIST,743250,CDM,981,RC,29260,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,24.23,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.95,35.9,
STRAPPING SHOULDER (EG VELPEAU,743300,CDM,981,RC,29240,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,17.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,23.03,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,17.06,34.12,
STRAPPING UNNA BOOT,743350,CDM,981,RC,29580,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,50.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,25.15,50.3,
THORACATOMY TUBE INS-PHYSICIAN,743500,CDM,981,RC,32020,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
THORACENTESIS INIT.,743550,CDM,981,RC,32000,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INCIS OF WINDPIPE EMERGENCY,743600,CDM,981,RC,31603,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,608.74,
OB CARE VAGINAL DELIVERY ONLY,743700,CDM,981,RC,59409,HCPCS,Outpatient,,,2311,1617.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1537.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,768.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1038.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,768.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,768.95,1537.9,
DELIVERY PLACENTA,743701,CDM,981,RC,59414,HCPCS,Outpatient,,,120,84,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,87.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,117.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,87.2,174.4,
REP COMP TRUNK 1.1 TO 2.5CM,743852,CDM,981,RC,13100,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,260,
REP COMP SCALP ARM LG 1.1-2.5C,743856,CDM,981,RC,13120,HCPCS,Outpatient,,,438,306.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,428.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,214.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,289.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,214.27,428.54,
REP COMP SCALP ARM LG 2.6-7.5C,743858,CDM,981,RC,13121,HCPCS,Outpatient,,,183,128.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,366,
REP COMP SCALP ARM LG EA ADD 5,743859,CDM,981,RC,13122,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,155.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,104.83,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,77.65,155.3,
REP COMP FACE NCK GEN HND FT 1,743860,CDM,981,RC,13131,HCPCS,Outpatient,,,458,320.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,450.86,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,225.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.43,450.86,
REP COMP FACE NCK GEN HND FT 2,743862,CDM,981,RC,13132,HCPCS,Outpatient,,,571,399.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,563.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,281.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,380.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,281.88,563.76,
"LACER.COMP.EYE,NOSE UP TO 1.0C",743864,CDM,981,RC,13150,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
REP COMP LID NS EAR LIP 1.1 TO,743866,CDM,981,RC,13151,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,260,
REP COMP LID NS EAR LIP 2.6 TO,743868,CDM,981,RC,13152,HCPCS,Outpatient,,,183,128.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,366,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,247.05,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183,366,
LYR CLS SCLP TRNK AXL EXTR < 2,743870,CDM,981,RC,12031,HCPCS,Outpatient,,,282,197.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,280.32,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,140.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.16,280.32,
LYR CLS SCLP TRNK AXL EXTR 2.6,743872,CDM,981,RC,12032,HCPCS,Outpatient,,,352,246.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,351.84,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,175.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,237.49,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.92,351.84,
LYR CLS SCLP TRNK AXL EXTR 7.6,743874,CDM,981,RC,12034,HCPCS,Outpatient,,,386,270.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,191.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.28,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.32,382.64,
LYR CLS SCLP TRNK AXL EXTR 12.,743875,CDM,981,RC,12035,HCPCS,Outpatient,,,455,318.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,451.7,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,225.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.85,451.7,
LYR CLS NCK HND FT GENIT < 2.5,743876,CDM,981,RC,12041,HCPCS,Outpatient,,,272,190.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,135.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.56,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.23,270.46,
LYR CLS NCK HND FT GENIT 2.6 T,743878,CDM,981,RC,12042,HCPCS,Outpatient,,,366,256.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,363.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,181.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,245.58,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,181.91,363.82,
LYR CLS NCK HND FT GENIT 7.6 T,743880,CDM,981,RC,12044,HCPCS,Outpatient,,,401,280.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,400.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,200.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.26,400.52,
LYR CLS FACE < 2.5CM,743882,CDM,981,RC,12051,HCPCS,Outpatient,,,315,220.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,314.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,157.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,212.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.37,314.74,
LYR CLS FACE 2.6 TO 5.0 CM,743884,CDM,981,RC,12052,HCPCS,Outpatient,,,373,261.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,250.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.51,371.02,
LYR CLS FACE 5.1 TO 7.5 CM,743886,CDM,981,RC,12053,HCPCS,Outpatient,,,404,282.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,401.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,200.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,270.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,200.55,401.1,
REP SMP SCP-NCK-AX-GN-TRNK-XTR,743888,CDM,981,RC,12001,HCPCS,Outpatient,,,131,91.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,42.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57.87,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,42.87,85.74,
REP SMP SCP-NK-GN-TRNK XTRM 2.,743890,CDM,981,RC,12002,HCPCS,Outpatient,,,154,107.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.02,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.29,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.51,113.02,
REP SMP SCP-NK-GN-TRNK-XTRM 7.,743892,CDM,981,RC,12004,HCPCS,Outpatient,,,196,137.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,95.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.77,141.54,
REP SMP SCP-NCK-GN-TRNK XTRM 1,743894,CDM,981,RC,12005,HCPCS,Outpatient,,,253,177.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,183.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.78,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.69,183.38,
REP SMP FACE < 2.5CM,743896,CDM,981,RC,12011,HCPCS,Outpatient,,,145,101.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,53.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,53.29,106.58,
REP SMP FACE 2.6 TO 7.5CM,743898,CDM,981,RC,12013,HCPCS,Outpatient,,,176,123.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.11,112.22,
REP SMP FACE 7.6 TO 12.6CM,743900,CDM,981,RC,12015,HCPCS,Outpatient,,,280,196,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,182.34,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,91.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,123.08,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.17,182.34,
WND CLOS W TISSUE ADHESIVE,743904,CDM,981,RC,G0168,HCPCS,Outpatient,,,74,51.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,28.52,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,14.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,19.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,14.26,28.52,
REPR LAC 2.5CM OR LESS MOUTH,743905,CDM,981,RC,41250,HCPCS,Outpatient,,,289,202.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,286.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,143.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,143.32,286.64,
CLTX CLAVICAL FX WO M,743906,CDM,981,RC,23500,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
TRT TAIL BONE FRACTURE,743908,CDM,981,RC,27200,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLOSD TRT BIMALL ANK W MAN,743910,CDM,981,RC,27810,HCPCS,Outpatient,,,499,349.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,817.24,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,408.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,551.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,408.62,817.24,
LIGATN OR BIOPSY TEMPORAL ARTE,743950,CDM,981,RC,37609,HCPCS,Outpatient,,,561,392.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,382.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,191.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,258.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,191.47,382.94,
CLTX FX FINGR THUMB W/O MAN,744000,CDM,981,RC,26750,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX PHLNGL DIS W MANI,744001,CDM,981,RC,26755,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTXMENT FEMUR FRAC,744002,CDM,981,RC,27230,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX PROX HUM FX WO M,744003,CDM,981,RC,23600,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX FX GREAT TOE WO MAN,744004,CDM,981,RC,28490,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX FX GREAT TOE W MAN,744005,CDM,981,RC,28495,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLSD TRT HUMERL TUBEROS FX WO,744006,CDM,981,RC,23620,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX MET FX W/O MAN,744008,CDM,981,RC,28470,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX METCRPL FX W MAN EA,744009,CDM,981,RC,26605,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTXMNT NASAL BONE FRAC,744010,CDM,981,RC,21310,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLTX PHLNGL FX NOT DISTAL W/MA,744012,CDM,981,RC,26725,HCPCS,Outpatient,,,571,399.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,582.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,291.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,393.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,291.47,582.94,
CLTX FINGER FX MTCRPHLNGL/IPHA,744014,CDM,981,RC,26740,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX FX PHALANX W MAN,744015,CDM,981,RC,28515,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX RAD & ULNA SHF WO MAN,744016,CDM,981,RC,25560,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
CLTX DS RD FX INC ULN ST W MAN,744017,CDM,981,RC,25605,HCPCS,Outpatient,,,168,117.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,336,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,168,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,226.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,336,
FRACTURE-RIB-UNCOMPLICATED-PHY,744018,CDM,981,RC,21800,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLTX SCAPULAR FRAC,744020,CDM,981,RC,23570,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
FRACTURE-SKULL W/O OPERATION-P,744022,CDM,981,RC,21300,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLTX TIB FX PROX WO M,744024,CDM,981,RC,27530,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
FRACTURE-ULNA-PHYSICIAN,744026,CDM,981,RC,25560,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
FRACTURE-VERTEBRAL PROCESS-PHY,744028,CDM,981,RC,22305,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLTX FRACTURE WRIST W MAN,744030,CDM,981,RC,25680,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
INSERT NON TUNNEL CV CATH 5+,744032,CDM,981,RC,36556,HCPCS,Outpatient,,,366,256.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,160.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.39,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,80.29,160.58,
INTRO CATH SUP INFER VENA CAVA,744034,CDM,981,RC,36010,HCPCS,Outpatient,,,57,39.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,114,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,57,114,
AVULSION NAIL PLATE SGL SIMP,744036,CDM,981,RC,11730,HCPCS,Outpatient,,,155,108.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,51.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,68.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,51.02,102.04,
EVACUATN OF SUBUNGUAL HEMATOMA,744038,CDM,981,RC,11740,HCPCS,Outpatient,,,165,115.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.16,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,39.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.58,59.16,
NAILS NAILBED RECONSTRUCTION-P,744040,CDM,981,RC,11762,HCPCS,Outpatient,,,183,128.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,350.94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,175.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.47,350.94,
I&D ABCESS MULT OR COMP,744042,CDM,981,RC,10061,HCPCS,Outpatient,,,342,239.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,343.4,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,231.8,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.7,343.4,
PUNCT ASPIR ABSCESS HEMA BULLA,744044,CDM,981,RC,10160,HCPCS,Outpatient,,,177,123.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,179.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,121.07,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.68,179.36,
DRAINAGE OF FINGER ABSCESS SIM,744046,CDM,981,RC,26010,HCPCS,Outpatient,,,261,182.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,262.9,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,177.46,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,131.45,262.9,
DRAIN FINGER ABSCESS COMP,744048,CDM,981,RC,26011,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
"I&D ARTHOCENTESIS,ASP.&INJ.;MA",744049,CDM,981,RC,20610,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,86.18,
INCIS PERIANAL ABSCESS SUPE,744050,CDM,981,RC,46050,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
INCISION THROMBOSED HERNIA EXT,744051,CDM,981,RC,46083,HCPCS,Outpatient,,,207,144.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.05,206.1,
I&D BART GL & ABSCESS,744052,CDM,981,RC,56420,HCPCS,Outpatient,,,205,143.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,206.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,103.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,139.67,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,103.46,206.92,
CONTROL NASAL HEMORR ANT SIMP,744054,CDM,981,RC,30901,HCPCS,Outpatient,,,109,76.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,108.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,54.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,73.18,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.21,108.42,
ENT INTUBATION ENDOTRACHEAL EM,744056,CDM,981,RC,31500,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
INCIS REMOV FB SUBQ COMP,744058,CDM,981,RC,10121,HCPCS,Outpatient,,,165,115.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,330,
REMOVE FOREIGN BODY FT SUBCU,744059,CDM,981,RC,28190,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,249.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.57,249.14,
FOR.BODY MUSCLE-SIMPLE-PHYSICI,744060,CDM,981,RC,20520,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,175.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130,260,
FOR.BODY MUSCLE DEEP/COMPLIC-P,744062,CDM,981,RC,20525,HCPCS,Outpatient,,,165,115.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,330,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,165,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,222.75,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,165,330,
REMOVE FOREIGN BODY PHARYNX,744064,CDM,981,RC,42809,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,168,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.4,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,84,168,
REMOVE FB EYE CONJ EMBED,744066,CDM,981,RC,65210,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,33.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,44.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,33.28,66.56,
REMOVE FB MOUTH SIMPLE,744067,CDM,981,RC,40804,HCPCS,Outpatient,,,273,191.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,210.06,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,105.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,141.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,105.03,210.06,
REMOVE IMPACTED CERUMEN,744068,CDM,981,RC,69210,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,61.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,30.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,41.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,30.9,61.8,
DEBRIDEMENT OF SKIN-PHYSICIAN,744069,CDM,981,RC,11040,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CLTXMNT TMJ DISLOCATN,744070,CDM,981,RC,21480,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,59.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,29.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,40.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,29.91,59.82,
CLTX ELBOW DISLOC WO ANES,744072,CDM,981,RC,24600,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,274,
CLTX ELBOW DISLOC W ANES,744073,CDM,981,RC,24605,HCPCS,Outpatient,,,666,466.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,904.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,452.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,610.71,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,452.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,452.38,904.76,
CLTX CARPOMETA DISLOC W MANIP,744074,CDM,981,RC,26641,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,184.95,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,137,274,
CLTX INTER JNT WO ANE,744076,CDM,981,RC,26770,HCPCS,Outpatient,,,489,342.3,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,506.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,253.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,341.62,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,253.05,506.1,
CLTX RADIAL HEAD SUBL,744077,CDM,981,RC,24640,HCPCS,Outpatient,,,226,158.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,150.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.79,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,75.4,150.8,
CLTX PATELLAR DISLOC,744078,CDM,981,RC,27560,HCPCS,Outpatient,,,954,667.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,652.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,326.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,440.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,326.1,652.2,
CLTX INTRPHLGL DISLOC TOE,744080,CDM,981,RC,28660,HCPCS,Outpatient,,,174,121.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,178.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,89.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,120.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.27,178.54,
CAST-LEG LONG -PHYSICIAN,744082,CDM,981,RC,29345,HCPCS,Outpatient,,,174,121.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.54,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,92.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.77,185.54,
CAST LEG SHORT-PHYSICIAN,744084,CDM,981,RC,29405,HCPCS,Outpatient,,,110,77,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,109.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,54.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,54.86,109.72,
CAST ARM LONG-PHYSICIAN,744086,CDM,981,RC,29065,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.26,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,63.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,85.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.63,127.26,
CAST ARM SHORT-PHYSICIAN,744088,CDM,981,RC,29075,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,116.46,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,58.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.61,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.23,116.46,
REPL GASTRO TUBE PERQ WO GUID,744089,CDM,981,RC,43762,HCPCS,Outpatient,,,114,79.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,71.58,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,35.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,48.32,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,35.79,71.58,
CAST HANGING-PHYSICIAN,744090,CDM,981,RC,,,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CAST BODY-PHYSICIAN,744092,CDM,981,RC,,,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
EWOL TUBE PLACEMENT-PHYSICIAN,744094,CDM,981,RC,91105,HCPCS,Outpatient,,,130,91,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
BREAST BIOPSY-NEEDLE-PHYSICIAN,744096,CDM,981,RC,19100,HCPCS,Outpatient,,,548,383.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,132.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,89.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,66.05,132.1,
BIOPSY OF SKIN-SINGLE LESION-P,744097,CDM,981,RC,11100,HCPCS,Outpatient,,,402,281.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
PARACENTESIS-PHYSICIAN,744098,CDM,981,RC,49080,HCPCS,Outpatient,,,366,256.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INSERT TEMP BLAD CATH COMPL,744100,CDM,981,RC,51703,HCPCS,Outpatient,,,147,102.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,144.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,97.48,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.21,144.42,
CARDIOPULMONARY RESUSCITATN,744102,CDM,981,RC,92950,HCPCS,Outpatient,,,360,252,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,349.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,174.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,236.24,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174.99,349.98,
SMP RPR F/E/E/N/L/M 5.1 CM-7.5,744103,CDM,981,RC,12014,HCPCS,Outpatient,,,212,148.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.28,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,72.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,98.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,72.64,145.28,
ARTHRO ASPIR INJ MAJOR JOINTS,744104,CDM,981,RC,20610,HCPCS,Outpatient,,,93,65.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,86.18,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,58.17,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,43.09,86.18,
TREAT METATARSAL FRACTURE,744105,CDM,981,RC,28470,HCPCS,Outpatient,,,238,166.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,386.12,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,193.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,260.63,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,193.06,386.12,
REP EXTEN TENDON HND WO GRPH,744106,CDM,981,RC,26410,HCPCS,Outpatient,,,641,448.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1098.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,549.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,741.77,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,549.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,549.46,1098.92,
ARTHRO ASPIR INJ INTERMED JNTS,744107,CDM,981,RC,20605,HCPCS,Outpatient,,,61,42.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,69.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,34.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,34.98,69.96,
RPR S/N/AX/GEN/TRNK >30.0 CM,744108,CDM,981,RC,12007,HCPCS,Outpatient,,,248,173.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,277.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,138.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,187.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.78,277.56,
RMVL SKIN TAGS UP TO&INC 15,744109,CDM,981,RC,11200,HCPCS,Outpatient,,,98,68.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.48,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,70.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.82,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,70.24,140.48,
REPR BLOOD VESSEL DIRECT LOWER,744110,CDM,981,RC,35226,HCPCS,Outpatient,,,1512,1058.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1564.62,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,782.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1056.12,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,782.31,1564.62,
DBRDMT SUBQ TIS 1ST 20SQCM/<,744111,CDM,981,RC,11042,HCPCS,Outpatient,,,137,95.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.98,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.94,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.99,113.98,
REPLACEMENT OF GASTROMY TUBE-P,744125,CDM,981,RC,43760,HCPCS,Outpatient,,,157,109.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
TRACHEOSTOMY EMERGENCY PROC TR,893550,CDM,981,RC,31603,HCPCS,Outpatient,,,926,648.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,608.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,410.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,304.37,608.74,
EKG INTERPRETATION,323350,CDM,981,RC,93010,HCPCS,Outpatient,,,35,24.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,15.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,10.38,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,7.69,15.38,
T & A <12,7503,CDM,982,RC,42820,HCPCS,Outpatient,,,363,254.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,5.47,Other,Not Seperately Reimbusable,,,,19.6,Other,Not Seperately Reimbusable,550.38,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,275.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,371.51,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,275.19,550.38,
ADENOIDECTOMY <12,7505,CDM,982,RC,42830,HCPCS,Outpatient,,,253,177.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,30.4,Other,Not Seperately Reimbusable,,,,360,Other,Not Seperately Reimbusable,399,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,199.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,269.33,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,199.5,399,
ADENOIDECTOMY >12,7506,CDM,982,RC,42831,HCPCS,Outpatient,,,270,189,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,8.51,Other,Not Seperately Reimbusable,,,,470,Other,Not Seperately Reimbusable,432.6,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,216.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,292.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,216.3,432.6,
MYRINGOTOMY WITH ANESTHESIA,7507,CDM,982,RC,69421,HCPCS,Outpatient,,,152,106.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,594.62,Other,Not Seperately Reimbusable,,,,5.2,Other,Not Seperately Reimbusable,281.1,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,140.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,189.74,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,140.55,281.1,
SEPTOPLASTY W/WO CARTILAGE SCO,7508,CDM,982,RC,30520,HCPCS,Outpatient,,,550,385,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,93.63,Other,Not Seperately Reimbusable,,,,3.2,Other,Not Seperately Reimbusable,1100,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,550,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,742.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,550,1100,
EXC SUBMANDIBULAR GLAND,7509,CDM,982,RC,42440,HCPCS,Outpatient,,,490,343,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,63.84,Other,Not Seperately Reimbusable,,,,133.6,Other,Not Seperately Reimbusable,785.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,392.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,530.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,392.91,785.82,
VENTILATING TUB REMOVAL W/ANES,7510,CDM,982,RC,69424,HCPCS,Outpatient,,,84,58.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,4.86,Other,Not Seperately Reimbusable,,,,4,Other,Not Seperately Reimbusable,112.82,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,76.15,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,56.41,112.82,
REM FB EAR W/ANESTHESIA,7511,CDM,982,RC,69205,HCPCS,Outpatient,,,132,92.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,2.43,Other,Not Seperately Reimbusable,,,,3.6,Other,Not Seperately Reimbusable,177.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,88.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,119.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,88.68,177.36,
INIT HOSP CARE PER DAY LOW SEV,740019,CDM,982,RC,99221,HCPCS,Outpatient,,,201,140.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,157.36,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,78.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,106.22,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,78.68,157.36,
OBSERV LOW CMPLEXITY,740979,CDM,982,RC,99218,HCPCS,Outpatient,,,196,137.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OBSRV/INPT HOSP CARE E&M LOW S,740980,CDM,982,RC,99234,HCPCS,Outpatient,,,262,183.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,185.92,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,92.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,125.5,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,92.96,185.92,
OBSRV/INPT HOSP CARE E&M HIGH,740981,CDM,982,RC,99236,HCPCS,Outpatient,,,426,298.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,396.22,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,198.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,267.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,198.11,396.22,
HOSP DISCH MGMNT > 30 MIN,740989,CDM,982,RC,99239,HCPCS,Outpatient,30,ME,207,144.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,215.76,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,107.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,145.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,107.88,215.76,
INIT HOSP CARE PER DAY HIGH SE,740990,CDM,982,RC,99223,HCPCS,Outpatient,,,395,276.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,328.78,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,164.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,221.93,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,164.39,328.78,
SUBSQT HOSP DAY E&M STABLE,740991,CDM,982,RC,99231,HCPCS,Outpatient,,,77,53.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.14,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,47.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.54,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47.07,94.14,
CRITCL CARE 1ST 30 74 MIN,740993,CDM,982,RC,99291,HCPCS,Outpatient,,,440,308,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,406.3,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,203.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,274.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.15,406.3,
CRITCL CARE EA ADD 30 MIN,740994,CDM,982,RC,99292,HCPCS,Outpatient,,,221,154.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.72,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,102.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,138.19,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,102.36,204.72,
OBSRV/INPT HOSP CARE E&M MOD S,740995,CDM,982,RC,99235,HCPCS,Outpatient,,,330,231,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302.74,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,151.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,204.35,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151.37,302.74,
OBSERV MODERATE COMPLEXITY,740996,CDM,982,RC,99219,HCPCS,Outpatient,,,265,185.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OBSERV HIGH COMPLEXITY,740997,CDM,982,RC,99220,HCPCS,Outpatient,,,362,253.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
OBSERVATION CARE DC DAY MGMNT,740998,CDM,982,RC,99217,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,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 CARE PER DAY MOD SEV,741002,CDM,982,RC,99222,HCPCS,Outpatient,,,270,189,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,248.04,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,124.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.43,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,124.02,248.04,
SUBSEQUENT OBSERVATION CARE ST,741003,CDM,982,RC,99224,HCPCS,Outpatient,,,78,54.6,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CONSULT LOW DESIC MOD SEVER,741004,CDM,982,RC,99243,HCPCS,Outpatient,,,131,91.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,167.56,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,83.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,113.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,83.78,167.56,
INPT CONSULT MOD SEVER,741005,CDM,982,RC,99253,HCPCS,Outpatient,,,135,94.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,188.96,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,94.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.55,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94.48,188.96,
SUBSQT HOSP DAY E&M MINOR COMP,741007,CDM,982,RC,99232,HCPCS,Outpatient,,,141,98.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,149.66,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,74.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,101.02,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,74.83,149.66,
SUBSQNT OBSERVATION CARE MINOR,741010,CDM,982,RC,99225,HCPCS,Outpatient,,,142,99.4,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSQNT OBSERVATN CARE SEVER C,741011,CDM,982,RC,99226,HCPCS,Outpatient,,,204,142.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
SUBSQT HOSP DAY E&M SIGNIF COM,741012,CDM,982,RC,99233,HCPCS,Outpatient,,,203,142.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,225.2,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,112.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,152.01,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,112.6,225.2,
CONSULT LOW DESIC MINOR SEVER,741013,CDM,982,RC,99241,HCPCS,Outpatient,,,65,45.5,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
CONSULT LOW DESIC LOW SEVER,741014,CDM,982,RC,99242,HCPCS,Outpatient,,,47,32.9,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,94,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,63.45,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,47,94,
CONSULT MOD DESIC MOD-HIGH SEV,741015,CDM,982,RC,99244,HCPCS,Outpatient,,,146,102.2,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,254.64,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,127.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,171.88,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,127.32,254.64,
CONSULT HIGH DESIC MOD-HIGH SE,741016,CDM,982,RC,99245,HCPCS,Outpatient,,,151,105.7,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,302,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,203.85,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,151,302,
INPT CONSULT LIMITED,741017,CDM,982,RC,99251,HCPCS,Outpatient,,,46,32.2,,,,,,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,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,
INPT CONSULT LOW SEVER,741018,CDM,982,RC,99252,HCPCS,Outpatient,,,113,79.1,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,135.42,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,67.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,91.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,67.71,135.42,
INPT CONSULT MOD-HIGH SEVER,741019,CDM,982,RC,99254,HCPCS,Outpatient,,,270,189,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,261.8,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,130.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,176.72,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,130.9,261.8,
INPT CONSULT HIGH SEVER,741020,CDM,982,RC,99255,HCPCS,Outpatient,,,174,121.8,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,348,200,,,Fee Schedule,200% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,174,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,234.9,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,174,348,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,664614.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,512702.97,135,MS-DRG,410162.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,379779.98,100,MS-DRG,303823.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,379779.98,100,MS-DRG,303823.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,379779.98,100,MS-DRG,303823.98,Case Rate,100% of CMS IPPS Rate,790,664614.97,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,303346.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,234010.49,135,MS-DRG,187208.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,173341.1,100,MS-DRG,138672.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,173341.1,100,MS-DRG,138672.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,173341.1,100,MS-DRG,138672.88,Case Rate,100% of CMS IPPS Rate,790,303346.93,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,524084.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,404293.45,135,MS-DRG,323434.76,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,299476.63,100,MS-DRG,239581.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,299476.63,100,MS-DRG,239581.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,299476.63,100,MS-DRG,239581.3,Case Rate,100% of CMS IPPS Rate,790,524084.1,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,363075.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,280086.82,135,MS-DRG,224069.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,207471.72,100,MS-DRG,165977.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,207471.72,100,MS-DRG,165977.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,207471.72,100,MS-DRG,165977.38,Case Rate,100% of CMS IPPS Rate,790,363075.51,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,257281.57,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,198474.35,135,MS-DRG,158779.48,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,147018.04,100,MS-DRG,117614.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,147018.04,100,MS-DRG,117614.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,147018.04,100,MS-DRG,117614.43,Case Rate,100% of CMS IPPS Rate,790,257281.57,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,123200.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,95040.41,135,MS-DRG,76032.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,70400.3,100,MS-DRG,56320.24,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,70400.3,100,MS-DRG,56320.24,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,70400.3,100,MS-DRG,56320.24,Case Rate,100% of CMS IPPS Rate,790,123200.53,
LUNG TRANSPLANT,7,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,303889.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,234428.86,135,MS-DRG,187543.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,173651.01,100,MS-DRG,138920.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,173651.01,100,MS-DRG,138920.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,173651.01,100,MS-DRG,138920.81,Case Rate,100% of CMS IPPS Rate,790,303889.27,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,133531.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,103010.29,135,MS-DRG,82408.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,76303.92,100,MS-DRG,61043.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,76303.92,100,MS-DRG,61043.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,76303.92,100,MS-DRG,61043.14,Case Rate,100% of CMS IPPS Rate,790,133531.86,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,122633.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,94603.26,135,MS-DRG,75682.61,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,70076.49,100,MS-DRG,56061.19,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,70076.49,100,MS-DRG,56061.19,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,70076.49,100,MS-DRG,56061.19,Case Rate,100% of CMS IPPS Rate,790,122633.86,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,130968.48,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,101032.83,135,MS-DRG,80826.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,74839.13,100,MS-DRG,59871.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,74839.13,100,MS-DRG,59871.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,74839.13,100,MS-DRG,59871.3,Case Rate,100% of CMS IPPS Rate,790,130968.48,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,102965.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,79430.85,135,MS-DRG,63544.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,58837.67,100,MS-DRG,47070.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,58837.67,100,MS-DRG,47070.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,58837.67,100,MS-DRG,47070.14,Case Rate,100% of CMS IPPS Rate,790,102965.92,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,70882.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,54680.68,135,MS-DRG,43744.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40504.21,100,MS-DRG,32403.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40504.21,100,MS-DRG,32403.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40504.21,100,MS-DRG,32403.37,Case Rate,100% of CMS IPPS Rate,790,70882.37,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,284299.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,219316.49,135,MS-DRG,175453.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,162456.66,100,MS-DRG,129965.33,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,162456.66,100,MS-DRG,129965.33,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,162456.66,100,MS-DRG,129965.33,Case Rate,100% of CMS IPPS Rate,790,284299.16,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,155792.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,120182.67,135,MS-DRG,96146.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,790,155792.35,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,155792.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,120182.67,135,MS-DRG,96146.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,89024.2,100,MS-DRG,71219.36,Case Rate,100% of CMS IPPS Rate,790,155792.35,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,901595.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,695516.73,135,MS-DRG,556413.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,515197.58,100,MS-DRG,412158.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,515197.58,100,MS-DRG,412158.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,515197.58,100,MS-DRG,412158.06,Case Rate,100% of CMS IPPS Rate,790,901595.77,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,199970.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,154262.92,135,MS-DRG,123410.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,114268.83,100,MS-DRG,91415.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,114268.83,100,MS-DRG,91415.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,114268.83,100,MS-DRG,91415.06,Case Rate,100% of CMS IPPS Rate,790,199970.45,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,211131.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,162872.56,135,MS-DRG,130298.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,120646.34,100,MS-DRG,96517.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,120646.34,100,MS-DRG,96517.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,120646.34,100,MS-DRG,96517.07,Case Rate,100% of CMS IPPS Rate,790,211131.1,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,154926.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,119514.76,135,MS-DRG,95611.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,88529.45,100,MS-DRG,70823.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,88529.45,100,MS-DRG,70823.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,88529.45,100,MS-DRG,70823.56,Case Rate,100% of CMS IPPS Rate,790,154926.54,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,100966.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77888.67,135,MS-DRG,62310.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57695.31,100,MS-DRG,46156.25,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57695.31,100,MS-DRG,46156.25,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57695.31,100,MS-DRG,46156.25,Case Rate,100% of CMS IPPS Rate,790,100966.79,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,143432.68,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,110648.07,135,MS-DRG,88518.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,81961.53,100,MS-DRG,65569.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,81961.53,100,MS-DRG,65569.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,81961.53,100,MS-DRG,65569.22,Case Rate,100% of CMS IPPS Rate,790,143432.68,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,97710.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,75376.49,135,MS-DRG,60301.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,55834.44,100,MS-DRG,44667.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,55834.44,100,MS-DRG,44667.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,55834.44,100,MS-DRG,44667.55,Case Rate,100% of CMS IPPS Rate,790,97710.27,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,112964.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,87143.72,135,MS-DRG,69714.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,64550.9,100,MS-DRG,51640.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,64550.9,100,MS-DRG,51640.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,64550.9,100,MS-DRG,51640.72,Case Rate,100% of CMS IPPS Rate,790,112964.08,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,77385.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59697.51,135,MS-DRG,47758.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44220.38,100,MS-DRG,35376.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44220.38,100,MS-DRG,35376.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44220.38,100,MS-DRG,35376.3,Case Rate,100% of CMS IPPS Rate,790,77385.67,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,64734.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,49937.8,135,MS-DRG,39950.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36990.96,100,MS-DRG,29592.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36990.96,100,MS-DRG,29592.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36990.96,100,MS-DRG,29592.77,Case Rate,100% of CMS IPPS Rate,790,64734.18,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,152122.41,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,117351.57,135,MS-DRG,93881.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,86927.09,100,MS-DRG,69541.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,86927.09,100,MS-DRG,69541.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,86927.09,100,MS-DRG,69541.67,Case Rate,100% of CMS IPPS Rate,790,152122.41,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,88940.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,68611.1,135,MS-DRG,54888.88,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50823.04,100,MS-DRG,40658.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50823.04,100,MS-DRG,40658.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50823.04,100,MS-DRG,40658.43,Case Rate,100% of CMS IPPS Rate,790,88940.32,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,61964.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,47800.88,135,MS-DRG,38240.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,35408.06,100,MS-DRG,28326.45,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,35408.06,100,MS-DRG,28326.45,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35408.06,100,MS-DRG,28326.45,Case Rate,100% of CMS IPPS Rate,790,61964.11,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,105682.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,81526.5,135,MS-DRG,65221.2,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,60390,100,MS-DRG,48312,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,60390,100,MS-DRG,48312,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,60390,100,MS-DRG,48312,Case Rate,100% of CMS IPPS Rate,790,105682.5,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57946.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44701.47,135,MS-DRG,35761.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33112.2,100,MS-DRG,26489.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33112.2,100,MS-DRG,26489.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33112.2,100,MS-DRG,26489.76,Case Rate,100% of CMS IPPS Rate,790,57946.35,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45034.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34740.99,135,MS-DRG,27792.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25734.07,100,MS-DRG,20587.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25734.07,100,MS-DRG,20587.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25734.07,100,MS-DRG,20587.26,Case Rate,100% of CMS IPPS Rate,790,45034.62,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,100448.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77489.04,135,MS-DRG,61991.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57399.29,100,MS-DRG,45919.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57399.29,100,MS-DRG,45919.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57399.29,100,MS-DRG,45919.43,Case Rate,100% of CMS IPPS Rate,790,100448.76,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,61489.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,47435,135,MS-DRG,37948,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,35137.04,100,MS-DRG,28109.63,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,35137.04,100,MS-DRG,28109.63,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35137.04,100,MS-DRG,28109.63,Case Rate,100% of CMS IPPS Rate,790,61489.82,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49541.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38217.51,135,MS-DRG,30574.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28309.27,100,MS-DRG,22647.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28309.27,100,MS-DRG,22647.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28309.27,100,MS-DRG,22647.42,Case Rate,100% of CMS IPPS Rate,790,49541.22,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,87661.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,67624.24,135,MS-DRG,54099.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50092.03,100,MS-DRG,40073.62,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50092.03,100,MS-DRG,40073.62,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50092.03,100,MS-DRG,40073.62,Case Rate,100% of CMS IPPS Rate,790,87661.05,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44475.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34309.47,135,MS-DRG,27447.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25414.42,100,MS-DRG,20331.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25414.42,100,MS-DRG,20331.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25414.42,100,MS-DRG,20331.54,Case Rate,100% of CMS IPPS Rate,790,44475.24,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33314.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,25699.84,135,MS-DRG,20559.87,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19036.92,100,MS-DRG,15229.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19036.92,100,MS-DRG,15229.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19036.92,100,MS-DRG,15229.54,Case Rate,100% of CMS IPPS Rate,790,33314.61,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,99210.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,76534.09,135,MS-DRG,61227.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,56691.92,100,MS-DRG,45353.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,56691.92,100,MS-DRG,45353.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,56691.92,100,MS-DRG,45353.54,Case Rate,100% of CMS IPPS Rate,790,99210.86,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59816.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46144.23,135,MS-DRG,36915.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34180.91,100,MS-DRG,27344.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34180.91,100,MS-DRG,27344.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34180.91,100,MS-DRG,27344.73,Case Rate,100% of CMS IPPS Rate,790,59816.59,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47877.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36934.2,135,MS-DRG,29547.36,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27358.67,100,MS-DRG,21886.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27358.67,100,MS-DRG,21886.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27358.67,100,MS-DRG,21886.94,Case Rate,100% of CMS IPPS Rate,790,47877.67,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,52856.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40774.67,135,MS-DRG,32619.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30203.46,100,MS-DRG,24162.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30203.46,100,MS-DRG,24162.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30203.46,100,MS-DRG,24162.77,Case Rate,100% of CMS IPPS Rate,790,52856.06,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29491.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22750.52,135,MS-DRG,18200.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16852.24,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16852.24,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16852.24,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,790,29491.42,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41401.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31938.04,135,MS-DRG,25550.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23657.81,100,MS-DRG,18926.25,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23657.81,100,MS-DRG,18926.25,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23657.81,100,MS-DRG,18926.25,Case Rate,100% of CMS IPPS Rate,790,41401.17,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31665.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24427.8,135,MS-DRG,19542.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18094.67,100,MS-DRG,14475.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18094.67,100,MS-DRG,14475.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18094.67,100,MS-DRG,14475.74,Case Rate,100% of CMS IPPS Rate,790,31665.67,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63788.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49207.97,135,MS-DRG,39366.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36450.35,100,MS-DRG,29160.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36450.35,100,MS-DRG,29160.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36450.35,100,MS-DRG,29160.28,Case Rate,100% of CMS IPPS Rate,790,63788.11,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38718.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29868.63,135,MS-DRG,23894.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22124.91,100,MS-DRG,17699.93,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22124.91,100,MS-DRG,17699.93,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22124.91,100,MS-DRG,17699.93,Case Rate,100% of CMS IPPS Rate,790,38718.59,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47588.28,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36710.96,135,MS-DRG,29368.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27193.3,100,MS-DRG,21754.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27193.3,100,MS-DRG,21754.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27193.3,100,MS-DRG,21754.64,Case Rate,100% of CMS IPPS Rate,790,47588.28,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34438.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26566.62,135,MS-DRG,21253.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19678.98,100,MS-DRG,15743.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19678.98,100,MS-DRG,15743.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19678.98,100,MS-DRG,15743.18,Case Rate,100% of CMS IPPS Rate,790,34438.22,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27390.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21129.54,135,MS-DRG,16903.63,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15651.51,100,MS-DRG,12521.21,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15651.51,100,MS-DRG,12521.21,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15651.51,100,MS-DRG,12521.21,Case Rate,100% of CMS IPPS Rate,790,27390.14,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,73730.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,56877.66,135,MS-DRG,45502.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42131.6,100,MS-DRG,33705.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42131.6,100,MS-DRG,33705.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42131.6,100,MS-DRG,33705.28,Case Rate,100% of CMS IPPS Rate,790,73730.3,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51085.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39408.86,135,MS-DRG,31527.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29191.75,100,MS-DRG,23353.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29191.75,100,MS-DRG,23353.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29191.75,100,MS-DRG,23353.4,Case Rate,100% of CMS IPPS Rate,790,51085.56,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41724.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32187.56,135,MS-DRG,25750.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23842.64,100,MS-DRG,19074.11,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23842.64,100,MS-DRG,19074.11,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23842.64,100,MS-DRG,19074.11,Case Rate,100% of CMS IPPS Rate,790,41724.62,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,54278.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41872.25,135,MS-DRG,33497.8,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31016.48,100,MS-DRG,24813.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31016.48,100,MS-DRG,24813.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31016.48,100,MS-DRG,24813.18,Case Rate,100% of CMS IPPS Rate,790,54278.84,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30284.28,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23362.16,135,MS-DRG,18689.73,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17305.3,100,MS-DRG,13844.24,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17305.3,100,MS-DRG,13844.24,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17305.3,100,MS-DRG,13844.24,Case Rate,100% of CMS IPPS Rate,790,30284.28,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22285.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17191.49,135,MS-DRG,13753.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12734.44,100,MS-DRG,10187.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12734.44,100,MS-DRG,10187.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12734.44,100,MS-DRG,10187.55,Case Rate,100% of CMS IPPS Rate,790,22285.27,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40024.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30876.13,135,MS-DRG,24700.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22871.21,100,MS-DRG,18296.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22871.21,100,MS-DRG,18296.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22871.21,100,MS-DRG,18296.97,Case Rate,100% of CMS IPPS Rate,790,40024.62,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26748.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20634.24,135,MS-DRG,16507.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15284.62,100,MS-DRG,12227.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15284.62,100,MS-DRG,12227.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15284.62,100,MS-DRG,12227.7,Case Rate,100% of CMS IPPS Rate,790,26748.09,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24989.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19277.78,135,MS-DRG,15422.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14279.84,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14279.84,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14279.84,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,790,24989.72,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49086.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37866.68,135,MS-DRG,30293.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28049.39,100,MS-DRG,22439.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28049.39,100,MS-DRG,22439.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28049.39,100,MS-DRG,22439.51,Case Rate,100% of CMS IPPS Rate,790,49086.43,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31388.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24213.94,135,MS-DRG,19371.15,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17936.25,100,MS-DRG,14349,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17936.25,100,MS-DRG,14349,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17936.25,100,MS-DRG,14349,Case Rate,100% of CMS IPPS Rate,790,31388.44,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24607.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18983.23,135,MS-DRG,15186.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14061.65,100,MS-DRG,11249.32,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14061.65,100,MS-DRG,11249.32,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14061.65,100,MS-DRG,11249.32,Case Rate,100% of CMS IPPS Rate,790,24607.89,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42361.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32679.11,135,MS-DRG,26143.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24206.75,100,MS-DRG,19365.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24206.75,100,MS-DRG,19365.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24206.75,100,MS-DRG,19365.4,Case Rate,100% of CMS IPPS Rate,790,42361.81,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30522.63,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23546.03,135,MS-DRG,18836.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17441.5,100,MS-DRG,13953.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17441.5,100,MS-DRG,13953.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17441.5,100,MS-DRG,13953.2,Case Rate,100% of CMS IPPS Rate,790,30522.63,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,52109.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40198.72,135,MS-DRG,32158.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29776.83,100,MS-DRG,23821.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29776.83,100,MS-DRG,23821.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29776.83,100,MS-DRG,23821.46,Case Rate,100% of CMS IPPS Rate,790,52109.45,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28000.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21600.45,135,MS-DRG,17280.36,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16000.33,100,MS-DRG,12800.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16000.33,100,MS-DRG,12800.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16000.33,100,MS-DRG,12800.26,Case Rate,100% of CMS IPPS Rate,790,28000.58,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42310.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32639.72,135,MS-DRG,26111.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24177.57,100,MS-DRG,19342.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24177.57,100,MS-DRG,19342.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24177.57,100,MS-DRG,19342.06,Case Rate,100% of CMS IPPS Rate,790,42310.75,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30296.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23371.52,135,MS-DRG,18697.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17312.24,100,MS-DRG,13849.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17312.24,100,MS-DRG,13849.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17312.24,100,MS-DRG,13849.79,Case Rate,100% of CMS IPPS Rate,790,30296.42,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23581.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18191.51,135,MS-DRG,14553.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13475.19,100,MS-DRG,10780.15,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13475.19,100,MS-DRG,10780.15,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13475.19,100,MS-DRG,10780.15,Case Rate,100% of CMS IPPS Rate,790,23581.58,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59281.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45731.47,135,MS-DRG,36585.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33875.16,100,MS-DRG,27100.13,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33875.16,100,MS-DRG,27100.13,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33875.16,100,MS-DRG,27100.13,Case Rate,100% of CMS IPPS Rate,790,59281.53,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27684.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21356.55,135,MS-DRG,17085.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15819.67,100,MS-DRG,12655.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15819.67,100,MS-DRG,12655.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15819.67,100,MS-DRG,12655.74,Case Rate,100% of CMS IPPS Rate,790,27684.42,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60974.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47037.27,135,MS-DRG,37629.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34842.42,100,MS-DRG,27873.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34842.42,100,MS-DRG,27873.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34842.42,100,MS-DRG,27873.94,Case Rate,100% of CMS IPPS Rate,790,60974.24,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38553.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29741.07,135,MS-DRG,23792.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22030.42,100,MS-DRG,17624.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22030.42,100,MS-DRG,17624.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22030.42,100,MS-DRG,17624.34,Case Rate,100% of CMS IPPS Rate,790,38553.24,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27932.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21547.93,135,MS-DRG,17238.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15961.43,100,MS-DRG,12769.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15961.43,100,MS-DRG,12769.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15961.43,100,MS-DRG,12769.14,Case Rate,100% of CMS IPPS Rate,790,27932.5,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60840.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,46934.1,135,MS-DRG,37547.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34766,100,MS-DRG,27812.8,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34766,100,MS-DRG,27812.8,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34766,100,MS-DRG,27812.8,Case Rate,100% of CMS IPPS Rate,790,60840.5,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37597.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29003.74,135,MS-DRG,23202.99,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21484.25,100,MS-DRG,17187.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21484.25,100,MS-DRG,17187.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21484.25,100,MS-DRG,17187.4,Case Rate,100% of CMS IPPS Rate,790,37597.44,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27117.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20919.41,135,MS-DRG,16735.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15495.86,100,MS-DRG,12396.69,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15495.86,100,MS-DRG,12396.69,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15495.86,100,MS-DRG,12396.69,Case Rate,100% of CMS IPPS Rate,790,27117.76,
CONCUSSION WITH MCC,88,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42867.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33069.34,135,MS-DRG,26455.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24495.81,100,MS-DRG,19596.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24495.81,100,MS-DRG,19596.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24495.81,100,MS-DRG,19596.65,Case Rate,100% of CMS IPPS Rate,790,42867.67,
CONCUSSION WITH CC,89,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33531.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25866.81,135,MS-DRG,20693.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19160.6,100,MS-DRG,15328.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19160.6,100,MS-DRG,15328.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19160.6,100,MS-DRG,15328.48,Case Rate,100% of CMS IPPS Rate,790,33531.05,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28299.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21831.2,135,MS-DRG,17464.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16171.26,100,MS-DRG,12937.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16171.26,100,MS-DRG,12937.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16171.26,100,MS-DRG,12937.01,Case Rate,100% of CMS IPPS Rate,790,28299.71,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49079.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37861.03,135,MS-DRG,30288.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28045.21,100,MS-DRG,22436.17,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28045.21,100,MS-DRG,22436.17,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28045.21,100,MS-DRG,22436.17,Case Rate,100% of CMS IPPS Rate,790,49079.12,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30520.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23544.15,135,MS-DRG,18835.32,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17440.11,100,MS-DRG,13952.09,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17440.11,100,MS-DRG,13952.09,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17440.11,100,MS-DRG,13952.09,Case Rate,100% of CMS IPPS Rate,790,30520.19,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24398.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18821.89,135,MS-DRG,15057.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13942.14,100,MS-DRG,11153.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13942.14,100,MS-DRG,11153.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13942.14,100,MS-DRG,11153.71,Case Rate,100% of CMS IPPS Rate,790,24398.75,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,93670.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,72260.21,135,MS-DRG,57808.17,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,53526.08,100,MS-DRG,42820.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,53526.08,100,MS-DRG,42820.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,53526.08,100,MS-DRG,42820.86,Case Rate,100% of CMS IPPS Rate,790,93670.64,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63549.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49024.12,135,MS-DRG,39219.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36314.16,100,MS-DRG,29051.33,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36314.16,100,MS-DRG,29051.33,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36314.16,100,MS-DRG,29051.33,Case Rate,100% of CMS IPPS Rate,790,63549.78,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58576.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45187.39,135,MS-DRG,36149.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33472.14,100,MS-DRG,26777.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33472.14,100,MS-DRG,26777.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33472.14,100,MS-DRG,26777.71,Case Rate,100% of CMS IPPS Rate,790,58576.25,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,94015.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,72526.62,135,MS-DRG,58021.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,53723.42,100,MS-DRG,42978.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,53723.42,100,MS-DRG,42978.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,53723.42,100,MS-DRG,42978.74,Case Rate,100% of CMS IPPS Rate,790,94015.99,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57963.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44714.61,135,MS-DRG,35771.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33121.93,100,MS-DRG,26497.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33121.93,100,MS-DRG,26497.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33121.93,100,MS-DRG,26497.54,Case Rate,100% of CMS IPPS Rate,790,57963.38,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37672.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29061.9,135,MS-DRG,23249.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21527.33,100,MS-DRG,17221.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21527.33,100,MS-DRG,17221.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21527.33,100,MS-DRG,17221.86,Case Rate,100% of CMS IPPS Rate,790,37672.83,
SEIZURES WITH MCC,100,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53780.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41487.63,135,MS-DRG,33190.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30731.58,100,MS-DRG,24585.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30731.58,100,MS-DRG,24585.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30731.58,100,MS-DRG,24585.26,Case Rate,100% of CMS IPPS Rate,790,53780.27,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27686.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21358.43,135,MS-DRG,17086.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15821.06,100,MS-DRG,12656.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15821.06,100,MS-DRG,12656.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15821.06,100,MS-DRG,12656.85,Case Rate,100% of CMS IPPS Rate,790,27686.86,
HEADACHES WITH MCC,102,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34910.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26930.58,135,MS-DRG,21544.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19948.58,100,MS-DRG,15958.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19948.58,100,MS-DRG,15958.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19948.58,100,MS-DRG,15958.86,Case Rate,100% of CMS IPPS Rate,790,34910.02,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26052.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20097.67,135,MS-DRG,16078.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14887.16,100,MS-DRG,11909.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14887.16,100,MS-DRG,11909.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14887.16,100,MS-DRG,11909.73,Case Rate,100% of CMS IPPS Rate,790,26052.53,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,66543.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,51333.67,135,MS-DRG,41066.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38024.94,100,MS-DRG,30419.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38024.94,100,MS-DRG,30419.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38024.94,100,MS-DRG,30419.95,Case Rate,100% of CMS IPPS Rate,790,66543.65,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35522.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27403.37,135,MS-DRG,21922.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20298.79,100,MS-DRG,16239.03,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20298.79,100,MS-DRG,16239.03,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20298.79,100,MS-DRG,16239.03,Case Rate,100% of CMS IPPS Rate,790,35522.88,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43611.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33643.44,135,MS-DRG,26914.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24921.07,100,MS-DRG,19936.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24921.07,100,MS-DRG,19936.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24921.07,100,MS-DRG,19936.86,Case Rate,100% of CMS IPPS Rate,790,43611.87,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50090.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38641.51,135,MS-DRG,30913.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28623.34,100,MS-DRG,22898.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28623.34,100,MS-DRG,22898.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28623.34,100,MS-DRG,22898.67,Case Rate,100% of CMS IPPS Rate,790,50090.85,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34710.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26776.75,135,MS-DRG,21421.4,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19834.63,100,MS-DRG,15867.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19834.63,100,MS-DRG,15867.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19834.63,100,MS-DRG,15867.7,Case Rate,100% of CMS IPPS Rate,790,34710.6,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36724.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28330.2,135,MS-DRG,22664.16,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20985.33,100,MS-DRG,16788.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20985.33,100,MS-DRG,16788.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20985.33,100,MS-DRG,16788.26,Case Rate,100% of CMS IPPS Rate,790,36724.33,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23671.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18260.9,135,MS-DRG,14608.72,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13526.59,100,MS-DRG,10821.27,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13526.59,100,MS-DRG,10821.27,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13526.59,100,MS-DRG,10821.27,Case Rate,100% of CMS IPPS Rate,790,23671.53,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25118.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19377.21,135,MS-DRG,15501.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14353.49,100,MS-DRG,11482.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14353.49,100,MS-DRG,11482.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14353.49,100,MS-DRG,11482.79,Case Rate,100% of CMS IPPS Rate,790,25118.61,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37714.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29093.8,135,MS-DRG,23275.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21550.96,100,MS-DRG,17240.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21550.96,100,MS-DRG,17240.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21550.96,100,MS-DRG,17240.77,Case Rate,100% of CMS IPPS Rate,790,37714.18,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24960.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19255.27,135,MS-DRG,15404.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14263.16,100,MS-DRG,11410.53,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14263.16,100,MS-DRG,11410.53,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14263.16,100,MS-DRG,11410.53,Case Rate,100% of CMS IPPS Rate,790,24960.53,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,70065.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,54050.31,135,MS-DRG,43240.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40037.27,100,MS-DRG,32029.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40037.27,100,MS-DRG,32029.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40037.27,100,MS-DRG,32029.82,Case Rate,100% of CMS IPPS Rate,790,70065.22,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30962.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23885.59,135,MS-DRG,19108.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17693.03,100,MS-DRG,14154.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17693.03,100,MS-DRG,14154.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17693.03,100,MS-DRG,14154.42,Case Rate,100% of CMS IPPS Rate,790,30962.8,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42159.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32523.39,135,MS-DRG,26018.71,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24091.4,100,MS-DRG,19273.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24091.4,100,MS-DRG,19273.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24091.4,100,MS-DRG,19273.12,Case Rate,100% of CMS IPPS Rate,790,42159.95,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26619.2,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,20534.81,135,MS-DRG,16427.85,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15210.97,100,MS-DRG,12168.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15210.97,100,MS-DRG,12168.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15210.97,100,MS-DRG,12168.78,Case Rate,100% of CMS IPPS Rate,790,26619.2,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34450.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26576.01,135,MS-DRG,21260.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19685.93,100,MS-DRG,15748.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19685.93,100,MS-DRG,15748.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19685.93,100,MS-DRG,15748.74,Case Rate,100% of CMS IPPS Rate,790,34450.38,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,97450.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,75175.75,135,MS-DRG,60140.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,55685.74,100,MS-DRG,44548.59,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,55685.74,100,MS-DRG,44548.59,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,55685.74,100,MS-DRG,44548.59,Case Rate,100% of CMS IPPS Rate,790,97450.05,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55949.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43161.16,135,MS-DRG,34528.93,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31971.23,100,MS-DRG,25576.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31971.23,100,MS-DRG,25576.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31971.23,100,MS-DRG,25576.98,Case Rate,100% of CMS IPPS Rate,790,55949.65,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43140.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33279.47,135,MS-DRG,26623.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24651.46,100,MS-DRG,19721.17,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24651.46,100,MS-DRG,19721.17,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24651.46,100,MS-DRG,19721.17,Case Rate,100% of CMS IPPS Rate,790,43140.06,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,86445.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,66686.17,135,MS-DRG,53348.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,49397.16,100,MS-DRG,39517.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,49397.16,100,MS-DRG,39517.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49397.16,100,MS-DRG,39517.73,Case Rate,100% of CMS IPPS Rate,790,86445.03,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47651.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36759.74,135,MS-DRG,29407.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27229.44,100,MS-DRG,21783.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27229.44,100,MS-DRG,21783.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27229.44,100,MS-DRG,21783.55,Case Rate,100% of CMS IPPS Rate,790,47651.52,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35262.66,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27202.62,135,MS-DRG,21762.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20150.09,100,MS-DRG,16120.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20150.09,100,MS-DRG,16120.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20150.09,100,MS-DRG,16120.07,Case Rate,100% of CMS IPPS Rate,790,35262.66,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56905.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43898.48,135,MS-DRG,35118.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32517.39,100,MS-DRG,26013.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32517.39,100,MS-DRG,26013.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32517.39,100,MS-DRG,26013.91,Case Rate,100% of CMS IPPS Rate,790,56905.43,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35620.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27478.43,135,MS-DRG,21982.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20354.39,100,MS-DRG,16283.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20354.39,100,MS-DRG,16283.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20354.39,100,MS-DRG,16283.51,Case Rate,100% of CMS IPPS Rate,790,35620.18,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27202.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20985.08,135,MS-DRG,16788.06,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15544.5,100,MS-DRG,12435.6,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15544.5,100,MS-DRG,12435.6,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15544.5,100,MS-DRG,12435.6,Case Rate,100% of CMS IPPS Rate,790,27202.88,
DYSEQUILIBRIUM,149,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23676.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18264.68,135,MS-DRG,14611.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,790,23676.43,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37534.21,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28954.96,135,MS-DRG,23163.97,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21448.12,100,MS-DRG,17158.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21448.12,100,MS-DRG,17158.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21448.12,100,MS-DRG,17158.5,Case Rate,100% of CMS IPPS Rate,790,37534.21,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24308.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18752.45,135,MS-DRG,15001.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13890.7,100,MS-DRG,11112.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13890.7,100,MS-DRG,11112.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13890.7,100,MS-DRG,11112.56,Case Rate,100% of CMS IPPS Rate,790,24308.73,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34462.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26585.37,135,MS-DRG,21268.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19692.87,100,MS-DRG,15754.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19692.87,100,MS-DRG,15754.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19692.87,100,MS-DRG,15754.3,Case Rate,100% of CMS IPPS Rate,790,34462.52,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23435.63,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18078.92,135,MS-DRG,14463.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13391.79,100,MS-DRG,10713.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13391.79,100,MS-DRG,10713.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13391.79,100,MS-DRG,10713.43,Case Rate,100% of CMS IPPS Rate,790,23435.63,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42974.68,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33151.9,135,MS-DRG,26521.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24556.96,100,MS-DRG,19645.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24556.96,100,MS-DRG,19645.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24556.96,100,MS-DRG,19645.57,Case Rate,100% of CMS IPPS Rate,790,42974.68,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28586.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22052.6,135,MS-DRG,17642.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16335.26,100,MS-DRG,13068.21,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16335.26,100,MS-DRG,13068.21,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16335.26,100,MS-DRG,13068.21,Case Rate,100% of CMS IPPS Rate,790,28586.71,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21507.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16591.14,135,MS-DRG,13272.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12289.73,100,MS-DRG,9831.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12289.73,100,MS-DRG,9831.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12289.73,100,MS-DRG,9831.78,Case Rate,100% of CMS IPPS Rate,790,21507.03,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47079.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36318.85,135,MS-DRG,29055.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26902.85,100,MS-DRG,21522.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26902.85,100,MS-DRG,21522.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26902.85,100,MS-DRG,21522.28,Case Rate,100% of CMS IPPS Rate,790,47079.99,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28389.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21900.65,135,MS-DRG,17520.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16222.7,100,MS-DRG,12978.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16222.7,100,MS-DRG,12978.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16222.7,100,MS-DRG,12978.16,Case Rate,100% of CMS IPPS Rate,790,28389.73,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21986.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16960.75,135,MS-DRG,13568.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12563.52,100,MS-DRG,10050.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12563.52,100,MS-DRG,10050.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12563.52,100,MS-DRG,10050.82,Case Rate,100% of CMS IPPS Rate,790,21986.16,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,120201.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,92727.11,135,MS-DRG,74181.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,68686.75,100,MS-DRG,54949.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,68686.75,100,MS-DRG,54949.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,68686.75,100,MS-DRG,54949.4,Case Rate,100% of CMS IPPS Rate,790,120201.81,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,67591.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,52142.27,135,MS-DRG,41713.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38623.9,100,MS-DRG,30899.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38623.9,100,MS-DRG,30899.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38623.9,100,MS-DRG,30899.12,Case Rate,100% of CMS IPPS Rate,790,67591.83,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51199.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39497.03,135,MS-DRG,31597.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29257.06,100,MS-DRG,23405.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29257.06,100,MS-DRG,23405.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29257.06,100,MS-DRG,23405.65,Case Rate,100% of CMS IPPS Rate,790,51199.86,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,104252.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,80423.35,135,MS-DRG,64338.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,59572.85,100,MS-DRG,47658.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,59572.85,100,MS-DRG,47658.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,59572.85,100,MS-DRG,47658.28,Case Rate,100% of CMS IPPS Rate,790,104252.49,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49823.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38435.13,135,MS-DRG,30748.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28470.47,100,MS-DRG,22776.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28470.47,100,MS-DRG,22776.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28470.47,100,MS-DRG,22776.38,Case Rate,100% of CMS IPPS Rate,790,49823.32,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38536.21,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29727.93,135,MS-DRG,23782.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22020.69,100,MS-DRG,17616.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22020.69,100,MS-DRG,17616.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22020.69,100,MS-DRG,17616.55,Case Rate,100% of CMS IPPS Rate,790,38536.21,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,80350.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,61984.56,135,MS-DRG,49587.65,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,45914.49,100,MS-DRG,36731.59,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,45914.49,100,MS-DRG,36731.59,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45914.49,100,MS-DRG,36731.59,Case Rate,100% of CMS IPPS Rate,790,80350.36,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39686.57,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30615.35,135,MS-DRG,24492.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22678.04,100,MS-DRG,18142.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22678.04,100,MS-DRG,18142.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22678.04,100,MS-DRG,18142.43,Case Rate,100% of CMS IPPS Rate,790,39686.57,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25400.74,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19594.86,135,MS-DRG,15675.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14514.71,100,MS-DRG,11611.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14514.71,100,MS-DRG,11611.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14514.71,100,MS-DRG,11611.77,Case Rate,100% of CMS IPPS Rate,790,25400.74,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46822.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36119.95,135,MS-DRG,28895.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26755.52,100,MS-DRG,21404.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26755.52,100,MS-DRG,21404.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26755.52,100,MS-DRG,21404.42,Case Rate,100% of CMS IPPS Rate,790,46822.16,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29561.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22804.94,135,MS-DRG,18243.95,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16892.55,100,MS-DRG,13514.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16892.55,100,MS-DRG,13514.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16892.55,100,MS-DRG,13514.04,Case Rate,100% of CMS IPPS Rate,790,29561.96,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24128.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18613.64,135,MS-DRG,14890.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13787.88,100,MS-DRG,11030.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13787.88,100,MS-DRG,11030.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13787.88,100,MS-DRG,11030.3,Case Rate,100% of CMS IPPS Rate,790,24128.79,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47838.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36904.19,135,MS-DRG,29523.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27336.44,100,MS-DRG,21869.15,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27336.44,100,MS-DRG,21869.15,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27336.44,100,MS-DRG,21869.15,Case Rate,100% of CMS IPPS Rate,790,47838.77,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32344.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24951.25,135,MS-DRG,19961,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18482.41,100,MS-DRG,14785.93,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18482.41,100,MS-DRG,14785.93,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18482.41,100,MS-DRG,14785.93,Case Rate,100% of CMS IPPS Rate,790,32344.22,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24992.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19279.66,135,MS-DRG,15423.73,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14281.23,100,MS-DRG,11424.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14281.23,100,MS-DRG,11424.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14281.23,100,MS-DRG,11424.98,Case Rate,100% of CMS IPPS Rate,790,24992.15,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43857.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33832.94,135,MS-DRG,27066.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25061.44,100,MS-DRG,20049.15,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25061.44,100,MS-DRG,20049.15,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25061.44,100,MS-DRG,20049.15,Case Rate,100% of CMS IPPS Rate,790,43857.52,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31147.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24028.2,135,MS-DRG,19222.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17798.67,100,MS-DRG,14238.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17798.67,100,MS-DRG,14238.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17798.67,100,MS-DRG,14238.94,Case Rate,100% of CMS IPPS Rate,790,31147.67,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23943.94,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18471.04,135,MS-DRG,14776.83,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13682.25,100,MS-DRG,10945.8,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13682.25,100,MS-DRG,10945.8,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13682.25,100,MS-DRG,10945.8,Case Rate,100% of CMS IPPS Rate,790,23943.94,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43312.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33412.69,135,MS-DRG,26730.15,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24750.14,100,MS-DRG,19800.11,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24750.14,100,MS-DRG,19800.11,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24750.14,100,MS-DRG,19800.11,Case Rate,100% of CMS IPPS Rate,790,43312.75,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29795.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22985.05,135,MS-DRG,18388.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17025.96,100,MS-DRG,13620.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17025.96,100,MS-DRG,13620.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17025.96,100,MS-DRG,13620.77,Case Rate,100% of CMS IPPS Rate,790,29795.43,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23720.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18298.43,135,MS-DRG,14638.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13554.39,100,MS-DRG,10843.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13554.39,100,MS-DRG,10843.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13554.39,100,MS-DRG,10843.51,Case Rate,100% of CMS IPPS Rate,790,23720.18,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35527.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27407.13,135,MS-DRG,21925.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20301.58,100,MS-DRG,16241.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20301.58,100,MS-DRG,16241.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20301.58,100,MS-DRG,16241.26,Case Rate,100% of CMS IPPS Rate,790,35527.77,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32366.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24968.13,135,MS-DRG,19974.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18494.91,100,MS-DRG,14795.93,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18494.91,100,MS-DRG,14795.93,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18494.91,100,MS-DRG,14795.93,Case Rate,100% of CMS IPPS Rate,790,32366.09,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26213.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20221.47,135,MS-DRG,16177.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14978.87,100,MS-DRG,11983.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14978.87,100,MS-DRG,11983.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14978.87,100,MS-DRG,11983.1,Case Rate,100% of CMS IPPS Rate,790,26213.02,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21173.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16334.1,135,MS-DRG,13067.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12099.33,100,MS-DRG,9679.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12099.33,100,MS-DRG,9679.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12099.33,100,MS-DRG,9679.46,Case Rate,100% of CMS IPPS Rate,790,21173.83,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37828.47,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29181.96,135,MS-DRG,23345.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21616.27,100,MS-DRG,17293.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21616.27,100,MS-DRG,17293.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21616.27,100,MS-DRG,17293.02,Case Rate,100% of CMS IPPS Rate,790,37828.47,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25561.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19718.67,135,MS-DRG,15774.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14606.42,100,MS-DRG,11685.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14606.42,100,MS-DRG,11685.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14606.42,100,MS-DRG,11685.14,Case Rate,100% of CMS IPPS Rate,790,25561.24,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20779.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16030.16,135,MS-DRG,12824.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11874.19,100,MS-DRG,9499.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11874.19,100,MS-DRG,9499.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11874.19,100,MS-DRG,9499.35,Case Rate,100% of CMS IPPS Rate,790,20779.83,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51661.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39853.49,135,MS-DRG,31882.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29521.1,100,MS-DRG,23616.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29521.1,100,MS-DRG,23616.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29521.1,100,MS-DRG,23616.88,Case Rate,100% of CMS IPPS Rate,790,51661.93,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29824.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23007.56,135,MS-DRG,18406.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17042.64,100,MS-DRG,13634.11,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17042.64,100,MS-DRG,13634.11,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17042.64,100,MS-DRG,13634.11,Case Rate,100% of CMS IPPS Rate,790,29824.62,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24491.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18893.18,135,MS-DRG,15114.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13994.95,100,MS-DRG,11195.96,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13994.95,100,MS-DRG,11195.96,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13994.95,100,MS-DRG,11195.96,Case Rate,100% of CMS IPPS Rate,790,24491.16,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48711.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37577.72,135,MS-DRG,30062.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27835.35,100,MS-DRG,22268.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27835.35,100,MS-DRG,22268.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27835.35,100,MS-DRG,22268.28,Case Rate,100% of CMS IPPS Rate,790,48711.86,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31758.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24499.11,135,MS-DRG,19599.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18147.49,100,MS-DRG,14517.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18147.49,100,MS-DRG,14517.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18147.49,100,MS-DRG,14517.99,Case Rate,100% of CMS IPPS Rate,790,31758.11,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22737.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17540.47,135,MS-DRG,14032.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12992.94,100,MS-DRG,10394.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12992.94,100,MS-DRG,10394.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12992.94,100,MS-DRG,10394.35,Case Rate,100% of CMS IPPS Rate,790,22737.65,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28851.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22257.11,135,MS-DRG,17805.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16486.75,100,MS-DRG,13189.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16486.75,100,MS-DRG,13189.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16486.75,100,MS-DRG,13189.4,Case Rate,100% of CMS IPPS Rate,790,28851.81,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22465.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17330.34,135,MS-DRG,13864.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12837.29,100,MS-DRG,10269.83,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12837.29,100,MS-DRG,10269.83,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12837.29,100,MS-DRG,10269.83,Case Rate,100% of CMS IPPS Rate,790,22465.26,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25578.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19731.8,135,MS-DRG,15785.44,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14616.15,100,MS-DRG,11692.92,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14616.15,100,MS-DRG,11692.92,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14616.15,100,MS-DRG,11692.92,Case Rate,100% of CMS IPPS Rate,790,25578.26,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49592.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38256.89,135,MS-DRG,30605.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28338.44,100,MS-DRG,22670.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28338.44,100,MS-DRG,22670.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28338.44,100,MS-DRG,22670.75,Case Rate,100% of CMS IPPS Rate,790,49592.27,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27781.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21431.6,135,MS-DRG,17145.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15875.26,100,MS-DRG,12700.21,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15875.26,100,MS-DRG,12700.21,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15875.26,100,MS-DRG,12700.21,Case Rate,100% of CMS IPPS Rate,790,27781.71,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,173570.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,133897.32,135,MS-DRG,107117.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,99183.2,100,MS-DRG,79346.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,99183.2,100,MS-DRG,79346.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,99183.2,100,MS-DRG,79346.56,Case Rate,100% of CMS IPPS Rate,790,173570.6,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,71322.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,55020.28,135,MS-DRG,44016.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40755.76,100,MS-DRG,32604.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40755.76,100,MS-DRG,32604.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40755.76,100,MS-DRG,32604.61,Case Rate,100% of CMS IPPS Rate,790,71322.58,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,267513.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,206367.32,135,MS-DRG,165093.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,152864.68,100,MS-DRG,122291.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,152864.68,100,MS-DRG,122291.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,152864.68,100,MS-DRG,122291.74,Case Rate,100% of CMS IPPS Rate,790,267513.19,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,253993.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,195937.8,135,MS-DRG,156750.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,145139.11,100,MS-DRG,116111.29,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,145139.11,100,MS-DRG,116111.29,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,145139.11,100,MS-DRG,116111.29,Case Rate,100% of CMS IPPS Rate,790,253993.44,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,241602.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,186378.81,135,MS-DRG,149103.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,138058.38,100,MS-DRG,110446.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,138058.38,100,MS-DRG,110446.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,138058.38,100,MS-DRG,110446.7,Case Rate,100% of CMS IPPS Rate,790,241602.17,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,160371.91,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,123715.47,135,MS-DRG,98972.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,91641.09,100,MS-DRG,73312.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,91641.09,100,MS-DRG,73312.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,91641.09,100,MS-DRG,73312.87,Case Rate,100% of CMS IPPS Rate,790,160371.91,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,144111.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,111171.54,135,MS-DRG,88937.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,82349.29,100,MS-DRG,65879.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,82349.29,100,MS-DRG,65879.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,82349.29,100,MS-DRG,65879.43,Case Rate,100% of CMS IPPS Rate,790,144111.26,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,193104.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,148966.55,135,MS-DRG,119173.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,110345.59,100,MS-DRG,88276.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,110345.59,100,MS-DRG,88276.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,110345.59,100,MS-DRG,88276.47,Case Rate,100% of CMS IPPS Rate,790,193104.78,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,133115.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,102689.46,135,MS-DRG,82151.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,76066.27,100,MS-DRG,60853.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,76066.27,100,MS-DRG,60853.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,76066.27,100,MS-DRG,60853.02,Case Rate,100% of CMS IPPS Rate,790,133115.97,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,118620.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,91507.62,135,MS-DRG,73206.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,67783.42,100,MS-DRG,54226.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,67783.42,100,MS-DRG,54226.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,67783.42,100,MS-DRG,54226.74,Case Rate,100% of CMS IPPS Rate,790,118620.99,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,128108.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,98826.47,135,MS-DRG,79061.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,73204.79,100,MS-DRG,58563.83,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,73204.79,100,MS-DRG,58563.83,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,73204.79,100,MS-DRG,58563.83,Case Rate,100% of CMS IPPS Rate,790,128108.38,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,82894.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,63947,135,MS-DRG,51157.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47368.15,100,MS-DRG,37894.52,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47368.15,100,MS-DRG,37894.52,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47368.15,100,MS-DRG,37894.52,Case Rate,100% of CMS IPPS Rate,790,82894.26,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,202930.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,156546.18,135,MS-DRG,125236.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,115960.13,100,MS-DRG,92768.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,115960.13,100,MS-DRG,92768.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,115960.13,100,MS-DRG,92768.1,Case Rate,100% of CMS IPPS Rate,790,202930.23,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,150237.55,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,115897.54,135,MS-DRG,92718.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,85850.03,100,MS-DRG,68680.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,85850.03,100,MS-DRG,68680.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,85850.03,100,MS-DRG,68680.02,Case Rate,100% of CMS IPPS Rate,790,150237.55,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,195254.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,150625.06,135,MS-DRG,120500.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,111574.12,100,MS-DRG,89259.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,111574.12,100,MS-DRG,89259.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,111574.12,100,MS-DRG,89259.3,Case Rate,100% of CMS IPPS Rate,790,195254.71,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,131980.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,101813.31,135,MS-DRG,81450.65,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,75417.27,100,MS-DRG,60333.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,75417.27,100,MS-DRG,60333.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,75417.27,100,MS-DRG,60333.82,Case Rate,100% of CMS IPPS Rate,790,131980.22,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,148583.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,114621.78,135,MS-DRG,91697.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,84905.02,100,MS-DRG,67924.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,84905.02,100,MS-DRG,67924.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,84905.02,100,MS-DRG,67924.02,Case Rate,100% of CMS IPPS Rate,790,148583.79,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,103848.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,80111.9,135,MS-DRG,64089.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,59342.15,100,MS-DRG,47473.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,59342.15,100,MS-DRG,47473.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,59342.15,100,MS-DRG,47473.72,Case Rate,100% of CMS IPPS Rate,790,103848.76,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,122468.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,94475.7,135,MS-DRG,75580.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,69982,100,MS-DRG,55985.6,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,69982,100,MS-DRG,55985.6,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,69982,100,MS-DRG,55985.6,Case Rate,100% of CMS IPPS Rate,790,122468.5,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,73885.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,56997.74,135,MS-DRG,45598.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42220.55,100,MS-DRG,33776.44,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42220.55,100,MS-DRG,33776.44,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42220.55,100,MS-DRG,33776.44,Case Rate,100% of CMS IPPS Rate,790,73885.96,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39467.68,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30446.5,135,MS-DRG,24357.2,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22552.96,100,MS-DRG,18042.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22552.96,100,MS-DRG,18042.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22552.96,100,MS-DRG,18042.37,Case Rate,100% of CMS IPPS Rate,790,39467.68,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,89594.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,69115.79,135,MS-DRG,55292.63,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,51196.88,100,MS-DRG,40957.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,51196.88,100,MS-DRG,40957.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51196.88,100,MS-DRG,40957.5,Case Rate,100% of CMS IPPS Rate,790,89594.54,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60957.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,47024.15,135,MS-DRG,37619.32,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34832.7,100,MS-DRG,27866.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34832.7,100,MS-DRG,27866.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34832.7,100,MS-DRG,27866.16,Case Rate,100% of CMS IPPS Rate,790,60957.23,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50059.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38617.11,135,MS-DRG,30893.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28605.27,100,MS-DRG,22884.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28605.27,100,MS-DRG,22884.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28605.27,100,MS-DRG,22884.22,Case Rate,100% of CMS IPPS Rate,790,50059.22,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,115770.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,89308.76,135,MS-DRG,71447.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,66154.64,100,MS-DRG,52923.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,66154.64,100,MS-DRG,52923.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,66154.64,100,MS-DRG,52923.71,Case Rate,100% of CMS IPPS Rate,790,115770.62,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,62737.47,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,48397.47,135,MS-DRG,38717.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,35849.98,100,MS-DRG,28679.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,35849.98,100,MS-DRG,28679.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35849.98,100,MS-DRG,28679.98,Case Rate,100% of CMS IPPS Rate,790,62737.47,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44159.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34065.59,135,MS-DRG,27252.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25233.77,100,MS-DRG,20187.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25233.77,100,MS-DRG,20187.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25233.77,100,MS-DRG,20187.02,Case Rate,100% of CMS IPPS Rate,790,44159.1,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,87130.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,67215.26,135,MS-DRG,53772.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,49789.08,100,MS-DRG,39831.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,49789.08,100,MS-DRG,39831.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49789.08,100,MS-DRG,39831.26,Case Rate,100% of CMS IPPS Rate,790,87130.89,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,67608.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,52155.4,135,MS-DRG,41724.32,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38633.63,100,MS-DRG,30906.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38633.63,100,MS-DRG,30906.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38633.63,100,MS-DRG,30906.9,Case Rate,100% of CMS IPPS Rate,790,67608.85,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47763.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36846.02,135,MS-DRG,29476.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27293.35,100,MS-DRG,21834.68,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27293.35,100,MS-DRG,21834.68,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27293.35,100,MS-DRG,21834.68,Case Rate,100% of CMS IPPS Rate,790,47763.36,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,72382.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,55838.28,135,MS-DRG,44670.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,41361.69,100,MS-DRG,33089.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,41361.69,100,MS-DRG,33089.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41361.69,100,MS-DRG,33089.35,Case Rate,100% of CMS IPPS Rate,790,72382.96,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45443.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35056.21,135,MS-DRG,28044.97,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25967.56,100,MS-DRG,20774.05,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25967.56,100,MS-DRG,20774.05,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25967.56,100,MS-DRG,20774.05,Case Rate,100% of CMS IPPS Rate,790,45443.23,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29666.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,22885.62,135,MS-DRG,18308.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16952.31,100,MS-DRG,13561.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16952.31,100,MS-DRG,13561.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16952.31,100,MS-DRG,13561.85,Case Rate,100% of CMS IPPS Rate,790,29666.54,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,71439.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,55110.35,135,MS-DRG,44088.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40822.48,100,MS-DRG,32657.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40822.48,100,MS-DRG,32657.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40822.48,100,MS-DRG,32657.98,Case Rate,100% of CMS IPPS Rate,790,71439.34,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50961.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39313.16,135,MS-DRG,31450.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29120.86,100,MS-DRG,23296.69,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29120.86,100,MS-DRG,23296.69,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29120.86,100,MS-DRG,23296.69,Case Rate,100% of CMS IPPS Rate,790,50961.51,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,86192.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,66491.05,135,MS-DRG,53192.84,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,49252.63,100,MS-DRG,39402.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,49252.63,100,MS-DRG,39402.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49252.63,100,MS-DRG,39402.1,Case Rate,100% of CMS IPPS Rate,790,86192.1,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51331.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39598.35,135,MS-DRG,31678.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29332.11,100,MS-DRG,23465.69,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29332.11,100,MS-DRG,23465.69,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29332.11,100,MS-DRG,23465.69,Case Rate,100% of CMS IPPS Rate,790,51331.19,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45579.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35161.25,135,MS-DRG,28129,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26045.37,100,MS-DRG,20836.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26045.37,100,MS-DRG,20836.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26045.37,100,MS-DRG,20836.3,Case Rate,100% of CMS IPPS Rate,790,45579.4,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,74275.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,57297.94,135,MS-DRG,45838.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42442.92,100,MS-DRG,33954.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42442.92,100,MS-DRG,33954.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42442.92,100,MS-DRG,33954.34,Case Rate,100% of CMS IPPS Rate,790,74275.11,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,84995.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,65568,135,MS-DRG,52454.4,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,48568.89,100,MS-DRG,38855.11,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,48568.89,100,MS-DRG,38855.11,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,48568.89,100,MS-DRG,38855.11,Case Rate,100% of CMS IPPS Rate,790,84995.56,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,91515.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,70597.95,135,MS-DRG,56478.36,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,52294.78,100,MS-DRG,41835.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,52294.78,100,MS-DRG,41835.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,52294.78,100,MS-DRG,41835.82,Case Rate,100% of CMS IPPS Rate,790,91515.87,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,157472.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,121479.09,135,MS-DRG,97183.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,89984.51,100,MS-DRG,71987.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,89984.51,100,MS-DRG,71987.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,89984.51,100,MS-DRG,71987.61,Case Rate,100% of CMS IPPS Rate,790,157472.89,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,124253.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,95852.77,135,MS-DRG,76682.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,71002.05,100,MS-DRG,56801.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,71002.05,100,MS-DRG,56801.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,71002.05,100,MS-DRG,56801.64,Case Rate,100% of CMS IPPS Rate,790,124253.59,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,172274.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,132897.33,135,MS-DRG,106317.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,98442.47,100,MS-DRG,78753.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,98442.47,100,MS-DRG,78753.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,98442.47,100,MS-DRG,78753.98,Case Rate,100% of CMS IPPS Rate,790,172274.32,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,106703.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,82314.5,135,MS-DRG,65851.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,60973.7,100,MS-DRG,48778.96,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,60973.7,100,MS-DRG,48778.96,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,60973.7,100,MS-DRG,48778.96,Case Rate,100% of CMS IPPS Rate,790,106703.98,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,128551.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,99167.94,135,MS-DRG,79334.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,73457.73,100,MS-DRG,58766.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,73457.73,100,MS-DRG,58766.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,73457.73,100,MS-DRG,58766.18,Case Rate,100% of CMS IPPS Rate,790,128551.03,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,89621.28,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,69136.42,135,MS-DRG,55309.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,51212.16,100,MS-DRG,40969.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,51212.16,100,MS-DRG,40969.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51212.16,100,MS-DRG,40969.73,Case Rate,100% of CMS IPPS Rate,790,89621.28,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,64894.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,50061.62,135,MS-DRG,40049.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37082.68,100,MS-DRG,29666.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37082.68,100,MS-DRG,29666.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37082.68,100,MS-DRG,29666.14,Case Rate,100% of CMS IPPS Rate,790,64894.69,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,100341.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77406.48,135,MS-DRG,61925.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57338.13,100,MS-DRG,45870.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57338.13,100,MS-DRG,45870.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57338.13,100,MS-DRG,45870.5,Case Rate,100% of CMS IPPS Rate,790,100341.73,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,84382.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,65095.22,135,MS-DRG,52076.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,48218.68,100,MS-DRG,38574.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,48218.68,100,MS-DRG,38574.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,48218.68,100,MS-DRG,38574.94,Case Rate,100% of CMS IPPS Rate,790,84382.69,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,176678.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,136295.04,135,MS-DRG,109036.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,100959.29,100,MS-DRG,80767.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,100959.29,100,MS-DRG,80767.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,100959.29,100,MS-DRG,80767.43,Case Rate,100% of CMS IPPS Rate,790,176678.76,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,156599.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,120805.56,135,MS-DRG,96644.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,89485.6,100,MS-DRG,71588.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,89485.6,100,MS-DRG,71588.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,89485.6,100,MS-DRG,71588.48,Case Rate,100% of CMS IPPS Rate,790,156599.8,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,121875.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,94017.92,135,MS-DRG,75214.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,69642.9,100,MS-DRG,55714.32,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,69642.9,100,MS-DRG,55714.32,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,69642.9,100,MS-DRG,55714.32,Case Rate,100% of CMS IPPS Rate,790,121875.08,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,114043.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,87976.71,135,MS-DRG,70381.37,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,65167.93,100,MS-DRG,52134.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,65167.93,100,MS-DRG,52134.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,65167.93,100,MS-DRG,52134.34,Case Rate,100% of CMS IPPS Rate,790,114043.88,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,83404.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,64340.99,135,MS-DRG,51472.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47659.99,100,MS-DRG,38127.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47659.99,100,MS-DRG,38127.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47659.99,100,MS-DRG,38127.99,Case Rate,100% of CMS IPPS Rate,790,83404.98,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44149.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34058.08,135,MS-DRG,27246.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25228.21,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25228.21,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25228.21,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,790,44149.37,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27769.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21422.22,135,MS-DRG,17137.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15868.31,100,MS-DRG,12694.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15868.31,100,MS-DRG,12694.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15868.31,100,MS-DRG,12694.65,Case Rate,100% of CMS IPPS Rate,790,27769.54,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23029.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17765.61,135,MS-DRG,14212.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13159.71,100,MS-DRG,10527.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13159.71,100,MS-DRG,10527.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13159.71,100,MS-DRG,10527.77,Case Rate,100% of CMS IPPS Rate,790,23029.49,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53510.31,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41279.38,135,MS-DRG,33023.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30577.32,100,MS-DRG,24461.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30577.32,100,MS-DRG,24461.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30577.32,100,MS-DRG,24461.86,Case Rate,100% of CMS IPPS Rate,790,53510.31,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23554.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18170.85,135,MS-DRG,14536.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13459.89,100,MS-DRG,10767.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13459.89,100,MS-DRG,10767.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13459.89,100,MS-DRG,10767.91,Case Rate,100% of CMS IPPS Rate,790,23554.81,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,17450.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13461.71,135,MS-DRG,10769.37,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,9971.64,100,MS-DRG,7977.31,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,9971.64,100,MS-DRG,7977.31,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,9971.64,100,MS-DRG,7977.31,Case Rate,100% of CMS IPPS Rate,790,17450.37,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57990.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44735.23,135,MS-DRG,35788.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33137.21,100,MS-DRG,26509.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33137.21,100,MS-DRG,26509.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33137.21,100,MS-DRG,26509.77,Case Rate,100% of CMS IPPS Rate,790,57990.12,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31869.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24585.4,135,MS-DRG,19668.32,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18211.41,100,MS-DRG,14569.13,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18211.41,100,MS-DRG,14569.13,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18211.41,100,MS-DRG,14569.13,Case Rate,100% of CMS IPPS Rate,790,31869.97,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,68627.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,52941.51,135,MS-DRG,42353.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39215.93,100,MS-DRG,31372.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39215.93,100,MS-DRG,31372.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39215.93,100,MS-DRG,31372.74,Case Rate,100% of CMS IPPS Rate,790,68627.88,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41503.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32016.84,135,MS-DRG,25613.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23716.18,100,MS-DRG,18972.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23716.18,100,MS-DRG,18972.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23716.18,100,MS-DRG,18972.94,Case Rate,100% of CMS IPPS Rate,790,41503.32,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31955.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24651.07,135,MS-DRG,19720.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18260.05,100,MS-DRG,14608.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18260.05,100,MS-DRG,14608.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18260.05,100,MS-DRG,14608.04,Case Rate,100% of CMS IPPS Rate,790,31955.09,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36789.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28380.85,135,MS-DRG,22704.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21022.85,100,MS-DRG,16818.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21022.85,100,MS-DRG,16818.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21022.85,100,MS-DRG,16818.28,Case Rate,100% of CMS IPPS Rate,790,36789.99,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26395.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20362.19,135,MS-DRG,16289.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15083.1,100,MS-DRG,12066.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15083.1,100,MS-DRG,12066.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15083.1,100,MS-DRG,12066.48,Case Rate,100% of CMS IPPS Rate,790,26395.43,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,19220.9,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14827.55,135,MS-DRG,11862.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,10983.37,100,MS-DRG,8786.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,10983.37,100,MS-DRG,8786.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,10983.37,100,MS-DRG,8786.7,Case Rate,100% of CMS IPPS Rate,790,19220.9,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32164.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24812.42,135,MS-DRG,19849.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18379.57,100,MS-DRG,14703.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18379.57,100,MS-DRG,14703.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18379.57,100,MS-DRG,14703.66,Case Rate,100% of CMS IPPS Rate,790,32164.25,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24950.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19247.76,135,MS-DRG,15398.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14257.6,100,MS-DRG,11406.08,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14257.6,100,MS-DRG,11406.08,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14257.6,100,MS-DRG,11406.08,Case Rate,100% of CMS IPPS Rate,790,24950.8,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44555.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34371.39,135,MS-DRG,27497.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25460.29,100,MS-DRG,20368.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25460.29,100,MS-DRG,20368.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25460.29,100,MS-DRG,20368.23,Case Rate,100% of CMS IPPS Rate,790,44555.51,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23284.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17962.6,135,MS-DRG,14370.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13305.63,100,MS-DRG,10644.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13305.63,100,MS-DRG,10644.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13305.63,100,MS-DRG,10644.5,Case Rate,100% of CMS IPPS Rate,790,23284.85,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,16258.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12542.42,135,MS-DRG,10033.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,9290.68,100,MS-DRG,7432.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,9290.68,100,MS-DRG,7432.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,9290.68,100,MS-DRG,7432.54,Case Rate,100% of CMS IPPS Rate,790,16258.69,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43898.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33864.84,135,MS-DRG,27091.87,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25085.07,100,MS-DRG,20068.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25085.07,100,MS-DRG,20068.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25085.07,100,MS-DRG,20068.06,Case Rate,100% of CMS IPPS Rate,790,43898.87,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31514.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24311.49,135,MS-DRG,19449.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18008.51,100,MS-DRG,14406.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18008.51,100,MS-DRG,14406.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18008.51,100,MS-DRG,14406.81,Case Rate,100% of CMS IPPS Rate,790,31514.89,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22827.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17609.87,135,MS-DRG,14087.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13044.35,100,MS-DRG,10435.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13044.35,100,MS-DRG,10435.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13044.35,100,MS-DRG,10435.48,Case Rate,100% of CMS IPPS Rate,790,22827.61,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32830.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25326.47,135,MS-DRG,20261.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18760.35,100,MS-DRG,15008.28,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18760.35,100,MS-DRG,15008.28,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18760.35,100,MS-DRG,15008.28,Case Rate,100% of CMS IPPS Rate,790,32830.61,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21570.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16639.92,135,MS-DRG,13311.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12325.87,100,MS-DRG,9860.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12325.87,100,MS-DRG,9860.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12325.87,100,MS-DRG,9860.7,Case Rate,100% of CMS IPPS Rate,790,21570.27,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33509.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25849.92,135,MS-DRG,20679.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19148.09,100,MS-DRG,15318.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19148.09,100,MS-DRG,15318.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19148.09,100,MS-DRG,15318.47,Case Rate,100% of CMS IPPS Rate,790,33509.16,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23890.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18429.75,135,MS-DRG,14743.8,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13651.67,100,MS-DRG,10921.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13651.67,100,MS-DRG,10921.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13651.67,100,MS-DRG,10921.34,Case Rate,100% of CMS IPPS Rate,790,23890.42,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42940.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33125.64,135,MS-DRG,26500.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24537.51,100,MS-DRG,19630.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24537.51,100,MS-DRG,19630.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24537.51,100,MS-DRG,19630.01,Case Rate,100% of CMS IPPS Rate,790,42940.64,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28489.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21977.55,135,MS-DRG,17582.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16279.67,100,MS-DRG,13023.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16279.67,100,MS-DRG,13023.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16279.67,100,MS-DRG,13023.74,Case Rate,100% of CMS IPPS Rate,790,28489.42,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34803.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26848.04,135,MS-DRG,21478.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19887.44,100,MS-DRG,15909.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19887.44,100,MS-DRG,15909.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19887.44,100,MS-DRG,15909.95,Case Rate,100% of CMS IPPS Rate,790,34803.02,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23676.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18264.68,135,MS-DRG,14611.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13529.39,100,MS-DRG,10823.51,Case Rate,100% of CMS IPPS Rate,790,23676.43,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,19014.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14668.09,135,MS-DRG,11734.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,10865.25,100,MS-DRG,8692.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,10865.25,100,MS-DRG,8692.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,10865.25,100,MS-DRG,8692.2,Case Rate,100% of CMS IPPS Rate,790,19014.19,
ANGINA PECTORIS,311,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22543.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17390.36,135,MS-DRG,13912.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12881.75,100,MS-DRG,10305.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12881.75,100,MS-DRG,10305.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12881.75,100,MS-DRG,10305.4,Case Rate,100% of CMS IPPS Rate,790,22543.06,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26565.68,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20493.53,135,MS-DRG,16394.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15180.39,100,MS-DRG,12144.31,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15180.39,100,MS-DRG,12144.31,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15180.39,100,MS-DRG,12144.31,Case Rate,100% of CMS IPPS Rate,790,26565.68,
CHEST PAIN,313,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23163.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17868.79,135,MS-DRG,14295.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13236.14,100,MS-DRG,10588.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13236.14,100,MS-DRG,10588.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13236.14,100,MS-DRG,10588.91,Case Rate,100% of CMS IPPS Rate,790,23163.25,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56479.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43570.16,135,MS-DRG,34856.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32274.19,100,MS-DRG,25819.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32274.19,100,MS-DRG,25819.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32274.19,100,MS-DRG,25819.35,Case Rate,100% of CMS IPPS Rate,790,56479.83,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29090.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22440.97,135,MS-DRG,17952.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16622.94,100,MS-DRG,13298.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16622.94,100,MS-DRG,13298.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16622.94,100,MS-DRG,13298.35,Case Rate,100% of CMS IPPS Rate,790,29090.15,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22411.74,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17289.06,135,MS-DRG,13831.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12806.71,100,MS-DRG,10245.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12806.71,100,MS-DRG,10245.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12806.71,100,MS-DRG,10245.37,Case Rate,100% of CMS IPPS Rate,790,22411.74,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,51039.23,Other,Not Seperately Reimbusable,790,1991.58,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,111648.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,86128.7,135,MS-DRG,68902.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,63799.04,100,MS-DRG,51039.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,63799.04,100,MS-DRG,51039.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,63799.04,100,MS-DRG,27292.48,Case Rate,100% of CMS IPPS Rate,790,111648.32,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59702.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46056.06,135,MS-DRG,36844.85,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34115.6,100,MS-DRG,27292.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34115.6,100,MS-DRG,27292.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34115.6,100,MS-DRG,34504.66,Case Rate,100% of CMS IPPS Rate,790,59702.3,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,75478.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,58226.62,135,MS-DRG,46581.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43130.83,100,MS-DRG,34504.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43130.83,100,MS-DRG,34504.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43130.83,100,MS-DRG,22816.4,Case Rate,100% of CMS IPPS Rate,790,75478.95,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49910.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38502.68,135,MS-DRG,30802.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28520.5,100,MS-DRG,22816.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28520.5,100,MS-DRG,22816.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28520.5,100,MS-DRG,48572.16,Case Rate,100% of CMS IPPS Rate,790,49910.88,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,106251.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,81965.52,135,MS-DRG,65572.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,60715.2,100,MS-DRG,48572.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,60715.2,100,MS-DRG,48572.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,60715.2,100,MS-DRG,35548.64,Case Rate,100% of CMS IPPS Rate,790,106251.6,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,77762.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59988.33,135,MS-DRG,47990.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44435.8,100,MS-DRG,35548.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44435.8,100,MS-DRG,35548.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44435.8,100,MS-DRG,31943.1,Case Rate,100% of CMS IPPS Rate,790,77762.65,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,69875.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,53903.97,135,MS-DRG,43123.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39928.87,100,MS-DRG,31943.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39928.87,100,MS-DRG,31943.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39928.87,100,MS-DRG,59011.88,Case Rate,100% of CMS IPPS Rate,790,69875.52,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,129088.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,99582.55,135,MS-DRG,79666.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,73764.85,100,MS-DRG,59011.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,73764.85,100,MS-DRG,59011.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,73764.85,100,MS-DRG,30309.87,Case Rate,100% of CMS IPPS Rate,790,129088.49,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,66302.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,51147.91,135,MS-DRG,40918.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37887.34,100,MS-DRG,30309.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37887.34,100,MS-DRG,30309.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37887.34,100,MS-DRG,20302.64,Case Rate,100% of CMS IPPS Rate,790,66302.85,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44412.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34260.71,135,MS-DRG,27408.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25378.3,100,MS-DRG,20302.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25378.3,100,MS-DRG,20302.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25378.3,100,MS-DRG,52761.39,Case Rate,100% of CMS IPPS Rate,790,44412.03,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,115415.55,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,89034.85,135,MS-DRG,71227.88,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,65951.74,100,MS-DRG,52761.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,65951.74,100,MS-DRG,52761.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,65951.74,100,MS-DRG,28916.79,Case Rate,100% of CMS IPPS Rate,790,115415.55,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63255.48,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,48797.09,135,MS-DRG,39037.67,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36145.99,100,MS-DRG,28916.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36145.99,100,MS-DRG,28916.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36145.99,100,MS-DRG,21133.14,Case Rate,100% of CMS IPPS Rate,790,63255.48,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46228.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35662.18,135,MS-DRG,28529.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26416.43,100,MS-DRG,21133.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26416.43,100,MS-DRG,21133.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26416.43,100,MS-DRG,43172.2,Case Rate,100% of CMS IPPS Rate,790,46228.75,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,94439.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,72853.09,135,MS-DRG,58282.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,53965.25,100,MS-DRG,43172.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,53965.25,100,MS-DRG,43172.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,53965.25,100,MS-DRG,25663.7,Case Rate,100% of CMS IPPS Rate,790,94439.19,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56139.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43307.49,135,MS-DRG,34645.99,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32079.62,100,MS-DRG,25663.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32079.62,100,MS-DRG,25663.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32079.62,100,MS-DRG,20389.35,Case Rate,100% of CMS IPPS Rate,790,56139.34,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44601.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34407.03,135,MS-DRG,27525.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25486.69,100,MS-DRG,20389.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25486.69,100,MS-DRG,20389.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25486.69,100,MS-DRG,42290.54,Case Rate,100% of CMS IPPS Rate,790,44601.71,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,92510.57,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,71365.29,135,MS-DRG,57092.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,52863.18,100,MS-DRG,42290.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,52863.18,100,MS-DRG,42290.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,52863.18,100,MS-DRG,25950.54,Case Rate,100% of CMS IPPS Rate,790,92510.57,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56766.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43791.54,135,MS-DRG,35033.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32438.18,100,MS-DRG,25950.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32438.18,100,MS-DRG,25950.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32438.18,100,MS-DRG,19180.85,Case Rate,100% of CMS IPPS Rate,790,56766.82,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41958.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32367.68,135,MS-DRG,25894.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23976.06,100,MS-DRG,19180.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23976.06,100,MS-DRG,19180.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23976.06,100,MS-DRG,33011.54,Case Rate,100% of CMS IPPS Rate,790,41958.11,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,72212.74,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,55706.97,135,MS-DRG,44565.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,41264.42,100,MS-DRG,33011.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,41264.42,100,MS-DRG,33011.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41264.42,100,MS-DRG,19672.25,Case Rate,100% of CMS IPPS Rate,790,72212.74,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43033.04,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33196.92,135,MS-DRG,26557.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24590.31,100,MS-DRG,19672.25,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24590.31,100,MS-DRG,19672.25,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24590.31,100,MS-DRG,16861.64,Case Rate,100% of CMS IPPS Rate,790,43033.04,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36884.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28454.02,135,MS-DRG,22763.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21077.05,100,MS-DRG,16861.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21077.05,100,MS-DRG,16861.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21077.05,100,MS-DRG,30884.67,Case Rate,100% of CMS IPPS Rate,790,36884.84,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,67560.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,52117.88,135,MS-DRG,41694.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38605.84,100,MS-DRG,30884.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38605.84,100,MS-DRG,30884.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38605.84,100,MS-DRG,17012.85,Case Rate,100% of CMS IPPS Rate,790,67560.22,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37215.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28709.18,135,MS-DRG,22967.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21266.06,100,MS-DRG,17012.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21266.06,100,MS-DRG,17012.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21266.06,100,MS-DRG,13392.85,Case Rate,100% of CMS IPPS Rate,790,37215.61,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29296.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,22600.43,135,MS-DRG,18080.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16741.06,100,MS-DRG,13392.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16741.06,100,MS-DRG,13392.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16741.06,100,MS-DRG,29226.99,Case Rate,100% of CMS IPPS Rate,790,29296.86,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63934.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,49320.55,135,MS-DRG,39456.44,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36533.74,100,MS-DRG,29226.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36533.74,100,MS-DRG,29226.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36533.74,100,MS-DRG,18727.23,Case Rate,100% of CMS IPPS Rate,790,63934.05,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40965.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31602.2,135,MS-DRG,25281.76,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23409.04,100,MS-DRG,18727.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23409.04,100,MS-DRG,18727.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23409.04,100,MS-DRG,14873.76,Case Rate,100% of CMS IPPS Rate,790,40965.82,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32536.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,25099.47,135,MS-DRG,20079.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18592.2,100,MS-DRG,14873.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18592.2,100,MS-DRG,14873.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18592.2,100,MS-DRG,35056.11,Case Rate,100% of CMS IPPS Rate,790,32536.35,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,76685.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59157.19,135,MS-DRG,47325.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43820.14,100,MS-DRG,35056.11,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43820.14,100,MS-DRG,35056.11,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43820.14,100,MS-DRG,21642.35,Case Rate,100% of CMS IPPS Rate,790,76685.25,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47342.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36521.47,135,MS-DRG,29217.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27052.94,100,MS-DRG,21642.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27052.94,100,MS-DRG,21642.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27052.94,100,MS-DRG,17693.26,Case Rate,100% of CMS IPPS Rate,790,47342.65,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38704.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29857.38,135,MS-DRG,23885.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22116.58,100,MS-DRG,17693.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22116.58,100,MS-DRG,17693.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22116.58,100,MS-DRG,50114.22,Case Rate,100% of CMS IPPS Rate,790,38704.02,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,109624.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,84567.74,135,MS-DRG,67654.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,62642.77,100,MS-DRG,50114.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,62642.77,100,MS-DRG,50114.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,62642.77,100,MS-DRG,26967.83,Case Rate,100% of CMS IPPS Rate,790,109624.85,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58992.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,45508.22,135,MS-DRG,36406.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33709.79,100,MS-DRG,26967.83,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33709.79,100,MS-DRG,26967.83,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33709.79,100,MS-DRG,16787.16,Case Rate,100% of CMS IPPS Rate,790,58992.13,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36721.91,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28328.33,135,MS-DRG,22662.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20983.95,100,MS-DRG,16787.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20983.95,100,MS-DRG,16787.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20983.95,100,MS-DRG,20910.79,Case Rate,100% of CMS IPPS Rate,790,36721.91,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45742.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35286.96,135,MS-DRG,28229.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26138.49,100,MS-DRG,20910.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26138.49,100,MS-DRG,20910.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26138.49,100,MS-DRG,13531.82,Case Rate,100% of CMS IPPS Rate,790,45742.36,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29600.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22834.95,135,MS-DRG,18267.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16914.78,100,MS-DRG,13531.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16914.78,100,MS-DRG,13531.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16914.78,100,MS-DRG,10812.38,Case Rate,100% of CMS IPPS Rate,790,29600.87,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23652.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18245.9,135,MS-DRG,14596.72,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13515.48,100,MS-DRG,10812.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13515.48,100,MS-DRG,10812.38,Case Rate,100% of CMS IPPS Rate,2500,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13515.48,100,MS-DRG,21974.77,Case Rate,100% of CMS IPPS Rate,790,23652.09,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48069.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37082.42,135,MS-DRG,29665.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27468.46,100,MS-DRG,21974.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27468.46,100,MS-DRG,21974.77,Case Rate,100% of CMS IPPS Rate,2500,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27468.46,100,MS-DRG,14132.19,Case Rate,100% of CMS IPPS Rate,790,48069.81,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30914.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23848.07,135,MS-DRG,19078.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17665.24,100,MS-DRG,14132.19,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17665.24,100,MS-DRG,14132.19,Case Rate,100% of CMS IPPS Rate,2000,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17665.24,100,MS-DRG,10509.98,Case Rate,100% of CMS IPPS Rate,790,30914.17,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22990.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17735.6,135,MS-DRG,14188.48,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13137.48,100,MS-DRG,10509.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13137.48,100,MS-DRG,10509.98,Case Rate,100% of CMS IPPS Rate,2000,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13137.48,100,MS-DRG,25880.5,Case Rate,100% of CMS IPPS Rate,790,22990.59,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56613.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43673.34,135,MS-DRG,34938.67,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32350.62,100,MS-DRG,25880.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32350.62,100,MS-DRG,25880.5,Case Rate,100% of CMS IPPS Rate,2000,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32350.62,100,MS-DRG,15866.59,Case Rate,100% of CMS IPPS Rate,790,56613.59,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34708.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26774.87,135,MS-DRG,21419.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19833.24,100,MS-DRG,15866.59,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19833.24,100,MS-DRG,15866.59,Case Rate,100% of CMS IPPS Rate,2000,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19833.24,100,MS-DRG,12454.5,Case Rate,100% of CMS IPPS Rate,790,34708.17,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27244.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21016.98,135,MS-DRG,16813.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15568.13,100,MS-DRG,12454.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15568.13,100,MS-DRG,12454.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15568.13,100,MS-DRG,22448.39,Case Rate,100% of CMS IPPS Rate,790,27244.23,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49105.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37881.66,135,MS-DRG,30305.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28060.49,100,MS-DRG,22448.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28060.49,100,MS-DRG,22448.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28060.49,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,790,49105.86,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29491.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22750.52,135,MS-DRG,18200.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16852.24,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16852.24,100,MS-DRG,13481.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16852.24,100,MS-DRG,9583.86,Case Rate,100% of CMS IPPS Rate,790,29491.42,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20964.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16172.76,135,MS-DRG,12938.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11979.82,100,MS-DRG,9583.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11979.82,100,MS-DRG,9583.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11979.82,100,MS-DRG,24207.26,Case Rate,100% of CMS IPPS Rate,790,20964.69,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,52953.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40849.76,135,MS-DRG,32679.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30259.08,100,MS-DRG,24207.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30259.08,100,MS-DRG,24207.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30259.08,100,MS-DRG,14473.51,Case Rate,100% of CMS IPPS Rate,790,52953.39,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31660.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24424.05,135,MS-DRG,19539.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18091.89,100,MS-DRG,14473.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18091.89,100,MS-DRG,14473.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18091.89,100,MS-DRG,10961.35,Case Rate,100% of CMS IPPS Rate,790,31660.81,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23977.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18497.28,135,MS-DRG,14797.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13701.69,100,MS-DRG,10961.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13701.69,100,MS-DRG,10961.35,Case Rate,100% of CMS IPPS Rate,500,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13701.69,100,MS-DRG,18089.06,Case Rate,100% of CMS IPPS Rate,500,23977.96,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39569.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30525.3,135,MS-DRG,24420.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22611.33,100,MS-DRG,18089.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22611.33,100,MS-DRG,18089.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22611.33,100,MS-DRG,12279.95,Case Rate,100% of CMS IPPS Rate,790,39569.83,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26862.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20722.42,135,MS-DRG,16577.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15349.94,100,MS-DRG,12279.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15349.94,100,MS-DRG,12279.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15349.94,100,MS-DRG,19964.66,Case Rate,100% of CMS IPPS Rate,790,26862.4,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43672.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33690.36,135,MS-DRG,26952.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24955.82,100,MS-DRG,19964.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24955.82,100,MS-DRG,19964.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24955.82,100,MS-DRG,13346.15,Case Rate,100% of CMS IPPS Rate,790,43672.69,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29194.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22521.63,135,MS-DRG,18017.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16682.69,100,MS-DRG,13346.15,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16682.69,100,MS-DRG,13346.15,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16682.69,100,MS-DRG,10149.76,Case Rate,100% of CMS IPPS Rate,790,29194.71,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22202.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17127.72,135,MS-DRG,13702.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12687.2,100,MS-DRG,10149.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12687.2,100,MS-DRG,10149.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12687.2,100,MS-DRG,18703.89,Case Rate,100% of CMS IPPS Rate,790,22202.6,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40914.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31562.81,135,MS-DRG,25250.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23379.86,100,MS-DRG,18703.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23379.86,100,MS-DRG,18703.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23379.86,100,MS-DRG,11398.3,Case Rate,100% of CMS IPPS Rate,790,40914.76,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24933.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19234.64,135,MS-DRG,15387.71,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14247.88,100,MS-DRG,11398.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14247.88,100,MS-DRG,11398.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14247.88,100,MS-DRG,8758.9,Case Rate,100% of CMS IPPS Rate,790,24933.79,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,19160.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14780.65,135,MS-DRG,11824.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,10948.63,100,MS-DRG,8758.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,10948.63,100,MS-DRG,8758.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,10948.63,100,MS-DRG,16727.12,Case Rate,100% of CMS IPPS Rate,790,19160.1,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36590.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28227.02,135,MS-DRG,22581.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20908.9,100,MS-DRG,16727.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20908.9,100,MS-DRG,16727.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20908.9,100,MS-DRG,11278.22,Case Rate,100% of CMS IPPS Rate,790,36590.58,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24671.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19032,135,MS-DRG,15225.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14097.78,100,MS-DRG,11278.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14097.78,100,MS-DRG,11278.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14097.78,100,MS-DRG,20550.57,Case Rate,100% of CMS IPPS Rate,790,24671.12,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44954.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34679.08,135,MS-DRG,27743.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25688.21,100,MS-DRG,20550.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25688.21,100,MS-DRG,20550.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25688.21,100,MS-DRG,12960.37,Case Rate,100% of CMS IPPS Rate,790,44954.37,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28350.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21870.62,135,MS-DRG,17496.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16200.46,100,MS-DRG,12960.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16200.46,100,MS-DRG,12960.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16200.46,100,MS-DRG,9742.84,Case Rate,100% of CMS IPPS Rate,790,28350.81,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21312.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16441.04,135,MS-DRG,13152.83,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12178.55,100,MS-DRG,9742.84,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12178.55,100,MS-DRG,9742.84,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12178.55,100,MS-DRG,27521.5,Case Rate,100% of CMS IPPS Rate,790,21312.46,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60203.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46442.52,135,MS-DRG,37154.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34401.87,100,MS-DRG,27521.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34401.87,100,MS-DRG,27521.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34401.87,100,MS-DRG,19368.74,Case Rate,100% of CMS IPPS Rate,790,60203.27,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42369.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32684.74,135,MS-DRG,26147.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24210.92,100,MS-DRG,19368.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24210.92,100,MS-DRG,19368.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24210.92,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,790,42369.11,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32636.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,25176.39,135,MS-DRG,20141.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18649.18,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18649.18,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18649.18,100,MS-DRG,63750.35,Case Rate,100% of CMS IPPS Rate,790,32636.07,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,34645.86,Other,Not Seperately Reimbusable,790,1991.58,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,139453.9,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,107578.72,135,MS-DRG,86062.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,79687.94,100,MS-DRG,63750.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,79687.94,100,MS-DRG,63750.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,79687.94,100,MS-DRG,26458.63,Case Rate,100% of CMS IPPS Rate,790,139453.9,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,75787.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,58464.9,135,MS-DRG,46771.92,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43307.33,100,MS-DRG,34645.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43307.33,100,MS-DRG,34645.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43307.33,100,MS-DRG,43927.1,Case Rate,100% of CMS IPPS Rate,790,75787.83,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57878.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44648.94,135,MS-DRG,35719.15,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33073.29,100,MS-DRG,26458.63,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33073.29,100,MS-DRG,26458.63,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33073.29,100,MS-DRG,24305.1,Case Rate,100% of CMS IPPS Rate,790,57878.26,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,96090.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,74126.99,135,MS-DRG,59301.59,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,54908.88,100,MS-DRG,43927.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,54908.88,100,MS-DRG,43927.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,54908.88,100,MS-DRG,19945.75,Case Rate,100% of CMS IPPS Rate,790,96090.54,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53167.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41014.85,135,MS-DRG,32811.88,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30381.37,100,MS-DRG,24305.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30381.37,100,MS-DRG,24305.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30381.37,100,MS-DRG,36346.91,Case Rate,100% of CMS IPPS Rate,790,53167.4,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43631.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33658.46,135,MS-DRG,26926.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24932.19,100,MS-DRG,19945.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24932.19,100,MS-DRG,19945.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24932.19,100,MS-DRG,25514.71,Case Rate,100% of CMS IPPS Rate,790,43631.33,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,79508.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,61335.41,135,MS-DRG,49068.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,45433.64,100,MS-DRG,36346.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,45433.64,100,MS-DRG,36346.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45433.64,100,MS-DRG,19327.59,Case Rate,100% of CMS IPPS Rate,790,79508.87,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55813.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43056.08,135,MS-DRG,34444.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31893.39,100,MS-DRG,25514.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31893.39,100,MS-DRG,25514.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31893.39,100,MS-DRG,41736.87,Case Rate,100% of CMS IPPS Rate,790,55813.43,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42279.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32615.31,135,MS-DRG,26092.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24159.49,100,MS-DRG,19327.59,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24159.49,100,MS-DRG,19327.59,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24159.49,100,MS-DRG,24510.77,Case Rate,100% of CMS IPPS Rate,790,42279.11,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,91299.41,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,70430.97,135,MS-DRG,56344.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,52171.09,100,MS-DRG,41736.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,52171.09,100,MS-DRG,41736.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,52171.09,100,MS-DRG,17433.1,Case Rate,100% of CMS IPPS Rate,790,91299.41,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53617.31,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41361.92,135,MS-DRG,33089.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30638.46,100,MS-DRG,24510.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30638.46,100,MS-DRG,24510.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30638.46,100,MS-DRG,28313.1,Case Rate,100% of CMS IPPS Rate,790,53617.31,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38134.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29418.36,135,MS-DRG,23534.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21791.38,100,MS-DRG,17433.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21791.38,100,MS-DRG,17433.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21791.38,100,MS-DRG,20718.45,Case Rate,100% of CMS IPPS Rate,790,38134.92,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,61934.9,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,47778.35,135,MS-DRG,38222.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,35391.37,100,MS-DRG,28313.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,35391.37,100,MS-DRG,28313.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35391.37,100,MS-DRG,17144.04,Case Rate,100% of CMS IPPS Rate,790,61934.9,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45321.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34962.38,135,MS-DRG,27969.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25898.06,100,MS-DRG,20718.45,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25898.06,100,MS-DRG,20718.45,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25898.06,100,MS-DRG,38130.22,Case Rate,100% of CMS IPPS Rate,790,45321.61,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37502.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28930.57,135,MS-DRG,23144.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21430.05,100,MS-DRG,17144.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21430.05,100,MS-DRG,17144.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21430.05,100,MS-DRG,21551.18,Case Rate,100% of CMS IPPS Rate,790,37502.59,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,83409.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,64344.74,135,MS-DRG,51475.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47662.77,100,MS-DRG,38130.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47662.77,100,MS-DRG,38130.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47662.77,100,MS-DRG,18231.37,Case Rate,100% of CMS IPPS Rate,790,83409.85,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47143.2,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36367.61,135,MS-DRG,29094.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26938.97,100,MS-DRG,21551.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26938.97,100,MS-DRG,21551.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26938.97,100,MS-DRG,46025.06,Case Rate,100% of CMS IPPS Rate,790,47143.2,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39881.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30765.43,135,MS-DRG,24612.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22789.21,100,MS-DRG,18231.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22789.21,100,MS-DRG,18231.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22789.21,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,790,39881.12,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,100679.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77667.28,135,MS-DRG,62133.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57531.32,100,MS-DRG,46025.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57531.32,100,MS-DRG,46025.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57531.32,100,MS-DRG,20353.78,Case Rate,100% of CMS IPPS Rate,790,100679.81,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57408.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44286.83,135,MS-DRG,35429.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32805.06,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32805.06,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32805.06,100,MS-DRG,23845.92,Case Rate,100% of CMS IPPS Rate,790,57408.86,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44523.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34347,135,MS-DRG,27477.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25442.22,100,MS-DRG,20353.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25442.22,100,MS-DRG,20353.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25442.22,100,MS-DRG,14006.55,Case Rate,100% of CMS IPPS Rate,790,44523.89,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,9987.43,Other,Not Seperately Reimbusable,790,1991.58,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,22110.41,Other,Not Seperately Reimbusable,790,1991.58,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,14781.48,Other,Not Seperately Reimbusable,790,1991.58,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,11784.1,Other,Not Seperately Reimbusable,790,1991.58,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,21097.57,Other,Not Seperately Reimbusable,790,1991.58,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,52162.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40239.99,135,MS-DRG,32191.99,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29807.4,100,MS-DRG,23845.92,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29807.4,100,MS-DRG,23845.92,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29807.4,100,MS-DRG,12052.02,Case Rate,100% of CMS IPPS Rate,790,52162.95,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30639.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23636.06,135,MS-DRG,18908.85,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17508.19,100,MS-DRG,14006.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17508.19,100,MS-DRG,14006.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17508.19,100,MS-DRG,9388.18,Case Rate,100% of CMS IPPS Rate,790,30639.33,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21847.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16853.79,135,MS-DRG,13483.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12484.29,100,MS-DRG,9987.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12484.29,100,MS-DRG,9987.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12484.29,100,MS-DRG,22869.77,Case Rate,100% of CMS IPPS Rate,790,21847.51,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48366.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37311.31,135,MS-DRG,29849.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27638.01,100,MS-DRG,22110.41,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27638.01,100,MS-DRG,22110.41,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27638.01,100,MS-DRG,13122.68,Case Rate,100% of CMS IPPS Rate,790,48366.52,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32334.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24943.75,135,MS-DRG,19955,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18476.85,100,MS-DRG,14781.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18476.85,100,MS-DRG,14781.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18476.85,100,MS-DRG,10489.97,Case Rate,100% of CMS IPPS Rate,790,32334.49,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25777.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19885.66,135,MS-DRG,15908.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14730.12,100,MS-DRG,11784.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14730.12,100,MS-DRG,11784.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14730.12,100,MS-DRG,20701.78,Case Rate,100% of CMS IPPS Rate,790,25777.71,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46150.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35602.15,135,MS-DRG,28481.72,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26371.96,100,MS-DRG,21097.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26371.96,100,MS-DRG,21097.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26371.96,100,MS-DRG,14626.94,Case Rate,100% of CMS IPPS Rate,790,46150.93,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26363.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20337.79,135,MS-DRG,16270.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15065.03,100,MS-DRG,12052.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15065.03,100,MS-DRG,12052.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15065.03,100,MS-DRG,11455,Case Rate,100% of CMS IPPS Rate,790,26363.8,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20536.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15842.56,135,MS-DRG,12674.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11735.23,100,MS-DRG,9388.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11735.23,100,MS-DRG,9388.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11735.23,100,MS-DRG,96261.36,Case Rate,100% of CMS IPPS Rate,790,20536.65,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50027.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38592.73,135,MS-DRG,30874.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28587.21,100,MS-DRG,22869.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28587.21,100,MS-DRG,22869.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28587.21,100,MS-DRG,70088.67,Case Rate,100% of CMS IPPS Rate,790,50027.62,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28705.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22144.52,135,MS-DRG,17715.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16403.35,100,MS-DRG,13122.68,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16403.35,100,MS-DRG,13122.68,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16403.35,100,MS-DRG,52919.27,Case Rate,100% of CMS IPPS Rate,790,28705.86,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22946.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17701.82,135,MS-DRG,14161.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13112.46,100,MS-DRG,10489.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13112.46,100,MS-DRG,10489.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13112.46,100,MS-DRG,78351.5,Case Rate,100% of CMS IPPS Rate,790,22946.81,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45285.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34934.25,135,MS-DRG,27947.4,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25877.22,100,MS-DRG,20701.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25877.22,100,MS-DRG,20701.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25877.22,100,MS-DRG,34188.91,Case Rate,100% of CMS IPPS Rate,790,45285.14,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31996.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24682.97,135,MS-DRG,19746.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18283.68,100,MS-DRG,14626.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18283.68,100,MS-DRG,14626.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18283.68,100,MS-DRG,65512.53,Case Rate,100% of CMS IPPS Rate,790,31996.44,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25057.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19330.31,135,MS-DRG,15464.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14318.75,100,MS-DRG,11455,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14318.75,100,MS-DRG,11455,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14318.75,100,MS-DRG,35913.31,Case Rate,100% of CMS IPPS Rate,790,25057.81,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,23343.4,Other,Not Seperately Reimbusable,790,1991.58,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,60208.18,Other,Not Seperately Reimbusable,790,1991.58,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,41304.38,Other,Not Seperately Reimbusable,790,1991.58,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,32224.38,Other,Not Seperately Reimbusable,790,1991.58,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,210571.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,162441.05,135,MS-DRG,129952.84,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,120326.7,100,MS-DRG,96261.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,120326.7,100,MS-DRG,96261.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,120326.7,100,MS-DRG,39564.43,Case Rate,100% of CMS IPPS Rate,790,210571.73,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,153318.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,118274.63,135,MS-DRG,94619.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,87610.84,100,MS-DRG,70088.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,87610.84,100,MS-DRG,70088.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,87610.84,100,MS-DRG,23464.58,Case Rate,100% of CMS IPPS Rate,790,153318.97,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,115760.91,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,89301.27,135,MS-DRG,71441.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,66149.09,100,MS-DRG,52919.27,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,66149.09,100,MS-DRG,52919.27,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,66149.09,100,MS-DRG,57233.02,Case Rate,100% of CMS IPPS Rate,790,115760.91,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,171393.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,132218.16,135,MS-DRG,105774.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,97939.38,100,MS-DRG,78351.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,97939.38,100,MS-DRG,78351.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,97939.38,100,MS-DRG,35401.88,Case Rate,100% of CMS IPPS Rate,790,171393.92,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,74788.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,57693.79,135,MS-DRG,46155.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42736.14,100,MS-DRG,34188.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42736.14,100,MS-DRG,34188.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42736.14,100,MS-DRG,29900.74,Case Rate,100% of CMS IPPS Rate,790,74788.25,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,143308.66,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,110552.39,135,MS-DRG,88441.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,81890.66,100,MS-DRG,65512.53,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,81890.66,100,MS-DRG,65512.53,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,81890.66,100,MS-DRG,50382.16,Case Rate,100% of CMS IPPS Rate,790,143308.66,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,78560.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,60603.71,135,MS-DRG,48482.97,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44891.64,100,MS-DRG,35913.31,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44891.64,100,MS-DRG,35913.31,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44891.64,100,MS-DRG,26388.58,Case Rate,100% of CMS IPPS Rate,790,78560.37,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51063.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39391.99,135,MS-DRG,31513.59,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29179.25,100,MS-DRG,23343.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29179.25,100,MS-DRG,23343.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29179.25,100,MS-DRG,15628.67,Case Rate,100% of CMS IPPS Rate,790,51063.69,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,131705.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,101601.3,135,MS-DRG,81281.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,75260.22,100,MS-DRG,60208.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,75260.22,100,MS-DRG,60208.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,75260.22,100,MS-DRG,40000.26,Case Rate,100% of CMS IPPS Rate,790,131705.39,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,90353.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,69701.15,135,MS-DRG,55760.92,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,51630.48,100,MS-DRG,41304.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,51630.48,100,MS-DRG,41304.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51630.48,100,MS-DRG,29045.76,Case Rate,100% of CMS IPPS Rate,790,90353.34,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,70490.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,54378.65,135,MS-DRG,43502.92,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40280.48,100,MS-DRG,32224.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40280.48,100,MS-DRG,32224.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40280.48,100,MS-DRG,23267.79,Case Rate,100% of CMS IPPS Rate,790,70490.84,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,86547.2,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,66764.98,135,MS-DRG,53411.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,49455.54,100,MS-DRG,39564.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,49455.54,100,MS-DRG,39564.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49455.54,100,MS-DRG,35329.62,Case Rate,100% of CMS IPPS Rate,790,86547.2,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51328.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39596.47,135,MS-DRG,31677.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29330.72,100,MS-DRG,23464.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29330.72,100,MS-DRG,23464.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29330.72,100,MS-DRG,25612.55,Case Rate,100% of CMS IPPS Rate,790,51328.76,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,125197.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,96580.73,135,MS-DRG,77264.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,71541.28,100,MS-DRG,57233.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,71541.28,100,MS-DRG,57233.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,71541.28,100,MS-DRG,20203.68,Case Rate,100% of CMS IPPS Rate,790,125197.24,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,77441.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59740.67,135,MS-DRG,47792.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44252.35,100,MS-DRG,35401.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44252.35,100,MS-DRG,35401.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44252.35,100,MS-DRG,30163.12,Case Rate,100% of CMS IPPS Rate,790,77441.61,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,65407.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,50457.51,135,MS-DRG,40366.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37375.93,100,MS-DRG,29900.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37375.93,100,MS-DRG,29900.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37375.93,100,MS-DRG,39166.41,Case Rate,100% of CMS IPPS Rate,790,65407.88,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,110210.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,85019.9,135,MS-DRG,68015.92,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,62977.7,100,MS-DRG,50382.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,62977.7,100,MS-DRG,50382.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,62977.7,100,MS-DRG,24872.1,Case Rate,100% of CMS IPPS Rate,790,110210.98,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57725.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44530.74,135,MS-DRG,35624.59,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32985.73,100,MS-DRG,26388.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32985.73,100,MS-DRG,26388.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32985.73,100,MS-DRG,19720.06,Case Rate,100% of CMS IPPS Rate,790,57725.03,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34187.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26373.38,135,MS-DRG,21098.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19535.84,100,MS-DRG,15628.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19535.84,100,MS-DRG,15628.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19535.84,100,MS-DRG,25965,Case Rate,100% of CMS IPPS Rate,790,34187.72,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,87500.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,67500.43,135,MS-DRG,54000.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50000.32,100,MS-DRG,40000.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50000.32,100,MS-DRG,40000.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50000.32,100,MS-DRG,16304.64,Case Rate,100% of CMS IPPS Rate,790,87500.56,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63537.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,49014.72,135,MS-DRG,39211.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36307.2,100,MS-DRG,29045.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36307.2,100,MS-DRG,29045.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36307.2,100,MS-DRG,41035.33,Case Rate,100% of CMS IPPS Rate,790,63537.6,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50898.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39264.4,135,MS-DRG,31411.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29084.74,100,MS-DRG,23267.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29084.74,100,MS-DRG,23267.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29084.74,100,MS-DRG,29245.89,Case Rate,100% of CMS IPPS Rate,790,50898.3,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,77283.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59618.73,135,MS-DRG,47694.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44162.02,100,MS-DRG,35329.62,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44162.02,100,MS-DRG,35329.62,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44162.02,100,MS-DRG,23325.61,Case Rate,100% of CMS IPPS Rate,790,77283.54,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56027.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43221.18,135,MS-DRG,34576.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32015.69,100,MS-DRG,25612.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32015.69,100,MS-DRG,25612.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32015.69,100,MS-DRG,42359.47,Case Rate,100% of CMS IPPS Rate,790,56027.46,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44195.55,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34093.71,135,MS-DRG,27274.97,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25254.6,100,MS-DRG,20203.68,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25254.6,100,MS-DRG,20203.68,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25254.6,100,MS-DRG,24640.84,Case Rate,100% of CMS IPPS Rate,790,44195.55,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,65981.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,50900.27,135,MS-DRG,40720.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37703.9,100,MS-DRG,30163.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37703.9,100,MS-DRG,30163.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37703.9,100,MS-DRG,18413.7,Case Rate,100% of CMS IPPS Rate,790,65981.83,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,85676.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,66093.31,135,MS-DRG,52874.65,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,48958.01,100,MS-DRG,39166.41,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,48958.01,100,MS-DRG,39166.41,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,48958.01,100,MS-DRG,31572.87,Case Rate,100% of CMS IPPS Rate,790,85676.52,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,54407.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41971.68,135,MS-DRG,33577.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31090.13,100,MS-DRG,24872.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31090.13,100,MS-DRG,24872.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31090.13,100,MS-DRG,16883.88,Case Rate,100% of CMS IPPS Rate,790,54407.73,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43137.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33277.61,135,MS-DRG,26622.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24650.08,100,MS-DRG,19720.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24650.08,100,MS-DRG,19720.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24650.08,100,MS-DRG,38597.18,Case Rate,100% of CMS IPPS Rate,790,43137.64,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56798.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43815.94,135,MS-DRG,35052.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32456.25,100,MS-DRG,25965,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32456.25,100,MS-DRG,25965,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32456.25,100,MS-DRG,21841.35,Case Rate,100% of CMS IPPS Rate,790,56798.44,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35666.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27514.08,135,MS-DRG,22011.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20380.8,100,MS-DRG,16304.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20380.8,100,MS-DRG,16304.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20380.8,100,MS-DRG,17916.74,Case Rate,100% of CMS IPPS Rate,790,35666.4,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,89764.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,69247.12,135,MS-DRG,55397.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,51294.16,100,MS-DRG,41035.33,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,51294.16,100,MS-DRG,41035.33,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51294.16,100,MS-DRG,32361.13,Case Rate,100% of CMS IPPS Rate,790,89764.78,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63975.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,49352.44,135,MS-DRG,39481.95,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36557.36,100,MS-DRG,29245.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36557.36,100,MS-DRG,29245.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36557.36,100,MS-DRG,21745.74,Case Rate,100% of CMS IPPS Rate,790,63975.38,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51024.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39361.96,135,MS-DRG,31489.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29157.01,100,MS-DRG,23325.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29157.01,100,MS-DRG,23325.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29157.01,100,MS-DRG,21507.82,Case Rate,100% of CMS IPPS Rate,790,51024.77,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,92661.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,71481.61,135,MS-DRG,57185.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,52949.34,100,MS-DRG,42359.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,52949.34,100,MS-DRG,42359.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,52949.34,100,MS-DRG,18805.06,Case Rate,100% of CMS IPPS Rate,790,92661.35,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53901.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41581.42,135,MS-DRG,33265.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30801.05,100,MS-DRG,24640.84,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30801.05,100,MS-DRG,24640.84,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30801.05,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,790,53901.84,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40279.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31073.13,135,MS-DRG,24858.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23017.13,100,MS-DRG,18413.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23017.13,100,MS-DRG,18413.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23017.13,100,MS-DRG,18487.08,Case Rate,100% of CMS IPPS Rate,790,40279.98,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,69065.66,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,53279.22,135,MS-DRG,42623.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39466.09,100,MS-DRG,31572.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39466.09,100,MS-DRG,31572.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39466.09,100,MS-DRG,17732.18,Case Rate,100% of CMS IPPS Rate,790,69065.66,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36933.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28491.55,135,MS-DRG,22793.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21104.85,100,MS-DRG,16883.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21104.85,100,MS-DRG,16883.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21104.85,100,MS-DRG,32791.38,Case Rate,100% of CMS IPPS Rate,790,36933.49,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,84431.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,65132.73,135,MS-DRG,52106.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,48246.47,100,MS-DRG,38597.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,48246.47,100,MS-DRG,38597.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,48246.47,100,MS-DRG,24710.88,Case Rate,100% of CMS IPPS Rate,790,84431.32,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47777.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36857.28,135,MS-DRG,29485.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27301.69,100,MS-DRG,21841.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27301.69,100,MS-DRG,21841.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27301.69,100,MS-DRG,20486.09,Case Rate,100% of CMS IPPS Rate,790,47777.96,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39192.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30234.49,135,MS-DRG,24187.59,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22395.92,100,MS-DRG,17916.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22395.92,100,MS-DRG,17916.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22395.92,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,790,39192.86,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,70789.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,54609.4,135,MS-DRG,43687.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40451.41,100,MS-DRG,32361.13,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40451.41,100,MS-DRG,32361.13,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40451.41,100,MS-DRG,14123.31,Case Rate,100% of CMS IPPS Rate,790,70789.97,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47568.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36695.94,135,MS-DRG,29356.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27182.18,100,MS-DRG,21745.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27182.18,100,MS-DRG,21745.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27182.18,100,MS-DRG,37693.29,Case Rate,100% of CMS IPPS Rate,790,47568.82,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47048.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36294.45,135,MS-DRG,29035.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26884.78,100,MS-DRG,21507.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26884.78,100,MS-DRG,21507.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26884.78,100,MS-DRG,25233.44,Case Rate,100% of CMS IPPS Rate,790,47048.37,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41136.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31733.53,135,MS-DRG,25386.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23506.32,100,MS-DRG,18805.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23506.32,100,MS-DRG,18805.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23506.32,100,MS-DRG,19158.61,Case Rate,100% of CMS IPPS Rate,790,41136.06,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57408.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44286.83,135,MS-DRG,35429.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32805.06,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32805.06,100,MS-DRG,26244.05,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32805.06,100,MS-DRG,43144.39,Case Rate,100% of CMS IPPS Rate,790,57408.86,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40440.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31196.95,135,MS-DRG,24957.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23108.85,100,MS-DRG,18487.08,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23108.85,100,MS-DRG,18487.08,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23108.85,100,MS-DRG,24430.72,Case Rate,100% of CMS IPPS Rate,790,40440.49,
ARTHROSCOPY,509,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38789.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29923.05,135,MS-DRG,23938.44,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22165.22,100,MS-DRG,17732.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22165.22,100,MS-DRG,17732.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22165.22,100,MS-DRG,18459.29,Case Rate,100% of CMS IPPS Rate,790,38789.14,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,71731.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,55335.46,135,MS-DRG,44268.37,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40989.23,100,MS-DRG,32791.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40989.23,100,MS-DRG,32791.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40989.23,100,MS-DRG,35833.26,Case Rate,100% of CMS IPPS Rate,790,71731.15,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,54055.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41699.61,135,MS-DRG,33359.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30888.6,100,MS-DRG,24710.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30888.6,100,MS-DRG,24710.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30888.6,100,MS-DRG,26027.26,Case Rate,100% of CMS IPPS Rate,790,54055.05,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44813.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34570.27,135,MS-DRG,27656.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25607.61,100,MS-DRG,20486.09,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25607.61,100,MS-DRG,20486.09,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25607.61,100,MS-DRG,20681.77,Case Rate,100% of CMS IPPS Rate,790,44813.32,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44988.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34705.37,135,MS-DRG,27764.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25707.68,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25707.68,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25707.68,100,MS-DRG,11549.5,Case Rate,100% of CMS IPPS Rate,790,44988.44,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30894.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23833.09,135,MS-DRG,19066.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17654.14,100,MS-DRG,14123.31,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17654.14,100,MS-DRG,14123.31,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17654.14,100,MS-DRG,16960.6,Case Rate,100% of CMS IPPS Rate,790,30894.75,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,82454.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,63607.42,135,MS-DRG,50885.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47116.61,100,MS-DRG,37693.29,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47116.61,100,MS-DRG,37693.29,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47116.61,100,MS-DRG,11294.9,Case Rate,100% of CMS IPPS Rate,790,82454.07,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55198.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,42581.43,135,MS-DRG,34065.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31541.8,100,MS-DRG,25233.44,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31541.8,100,MS-DRG,25233.44,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31541.8,100,MS-DRG,13295.02,Case Rate,100% of CMS IPPS Rate,790,55198.15,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41909.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32330.15,135,MS-DRG,25864.12,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23948.26,100,MS-DRG,19158.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23948.26,100,MS-DRG,19158.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23948.26,100,MS-DRG,10427.71,Case Rate,100% of CMS IPPS Rate,790,41909.46,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,94378.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,72806.16,135,MS-DRG,58244.93,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,53930.49,100,MS-DRG,43144.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,53930.49,100,MS-DRG,43144.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,53930.49,100,MS-DRG,24606.38,Case Rate,100% of CMS IPPS Rate,790,94378.36,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53442.2,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41226.84,135,MS-DRG,32981.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30538.4,100,MS-DRG,24430.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30538.4,100,MS-DRG,24430.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30538.4,100,MS-DRG,16977.27,Case Rate,100% of CMS IPPS Rate,790,53442.2,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40379.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31150.05,135,MS-DRG,24920.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23074.11,100,MS-DRG,18459.29,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23074.11,100,MS-DRG,18459.29,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23074.11,100,MS-DRG,12082.06,Case Rate,100% of CMS IPPS Rate,790,40379.69,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,78385.25,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,60468.62,135,MS-DRG,48374.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44791.57,100,MS-DRG,35833.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44791.57,100,MS-DRG,35833.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44791.57,100,MS-DRG,22819.74,Case Rate,100% of CMS IPPS Rate,790,78385.25,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56934.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43920.99,135,MS-DRG,35136.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32534.07,100,MS-DRG,26027.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32534.07,100,MS-DRG,26027.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32534.07,100,MS-DRG,14670.3,Case Rate,100% of CMS IPPS Rate,790,56934.62,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45241.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34900.48,135,MS-DRG,27920.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25852.21,100,MS-DRG,20681.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25852.21,100,MS-DRG,20681.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25852.21,100,MS-DRG,11076.99,Case Rate,100% of CMS IPPS Rate,790,45241.37,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25264.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19489.79,135,MS-DRG,15591.83,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14436.88,100,MS-DRG,11549.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14436.88,100,MS-DRG,11549.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14436.88,100,MS-DRG,30263.18,Case Rate,100% of CMS IPPS Rate,790,25264.54,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37101.31,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28621.01,135,MS-DRG,22896.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21200.75,100,MS-DRG,16960.6,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21200.75,100,MS-DRG,16960.6,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21200.75,100,MS-DRG,15877.71,Case Rate,100% of CMS IPPS Rate,790,37101.31,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24707.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19060.14,135,MS-DRG,15248.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14118.62,100,MS-DRG,11294.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14118.62,100,MS-DRG,11294.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14118.62,100,MS-DRG,11697.37,Case Rate,100% of CMS IPPS Rate,790,24707.59,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29082.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22435.34,135,MS-DRG,17948.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16618.77,100,MS-DRG,13295.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16618.77,100,MS-DRG,13295.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16618.77,100,MS-DRG,24221.7,Case Rate,100% of CMS IPPS Rate,790,29082.85,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22810.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17596.76,135,MS-DRG,14077.41,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13034.64,100,MS-DRG,10427.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13034.64,100,MS-DRG,10427.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13034.64,100,MS-DRG,15954.42,Case Rate,100% of CMS IPPS Rate,790,22810.62,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53826.47,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41523.27,135,MS-DRG,33218.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30757.98,100,MS-DRG,24606.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30757.98,100,MS-DRG,24606.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30757.98,100,MS-DRG,13033.75,Case Rate,100% of CMS IPPS Rate,790,53826.47,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37137.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28649.15,135,MS-DRG,22919.32,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21221.59,100,MS-DRG,16977.27,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21221.59,100,MS-DRG,16977.27,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21221.59,100,MS-DRG,21465.58,Case Rate,100% of CMS IPPS Rate,790,37137.78,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26429.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20388.47,135,MS-DRG,16310.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15102.57,100,MS-DRG,12082.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15102.57,100,MS-DRG,12082.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15102.57,100,MS-DRG,13287.24,Case Rate,100% of CMS IPPS Rate,790,26429.5,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49918.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38508.32,135,MS-DRG,30806.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28524.68,100,MS-DRG,22819.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28524.68,100,MS-DRG,22819.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28524.68,100,MS-DRG,17569.85,Case Rate,100% of CMS IPPS Rate,790,49918.19,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32091.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24756.12,135,MS-DRG,19804.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18337.87,100,MS-DRG,14670.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18337.87,100,MS-DRG,14670.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18337.87,100,MS-DRG,11680.7,Case Rate,100% of CMS IPPS Rate,790,32091.27,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24230.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18692.42,135,MS-DRG,14953.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13846.24,100,MS-DRG,11076.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13846.24,100,MS-DRG,11076.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13846.24,100,MS-DRG,18097.95,Case Rate,100% of CMS IPPS Rate,790,24230.92,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,66200.7,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51069.11,135,MS-DRG,40855.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37828.97,100,MS-DRG,30263.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37828.97,100,MS-DRG,30263.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37828.97,100,MS-DRG,11709.61,Case Rate,100% of CMS IPPS Rate,790,66200.7,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34732.5,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26793.64,135,MS-DRG,21434.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19847.14,100,MS-DRG,15877.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19847.14,100,MS-DRG,15877.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19847.14,100,MS-DRG,19852.37,Case Rate,100% of CMS IPPS Rate,790,34732.5,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25587.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19739.31,135,MS-DRG,15791.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14621.71,100,MS-DRG,11697.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14621.71,100,MS-DRG,11697.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14621.71,100,MS-DRG,12309.97,Case Rate,100% of CMS IPPS Rate,790,25587.99,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,52984.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40874.13,135,MS-DRG,32699.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30277.13,100,MS-DRG,24221.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30277.13,100,MS-DRG,24221.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30277.13,100,MS-DRG,23117.7,Case Rate,100% of CMS IPPS Rate,790,52984.98,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34900.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26923.08,135,MS-DRG,21538.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19943.02,100,MS-DRG,15954.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19943.02,100,MS-DRG,15954.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19943.02,100,MS-DRG,15130.58,Case Rate,100% of CMS IPPS Rate,790,34900.29,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28511.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21994.46,135,MS-DRG,17595.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16292.19,100,MS-DRG,13033.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16292.19,100,MS-DRG,13033.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16292.19,100,MS-DRG,11218.19,Case Rate,100% of CMS IPPS Rate,790,28511.33,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46955.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36223.16,135,MS-DRG,28978.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26831.97,100,MS-DRG,21465.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26831.97,100,MS-DRG,21465.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26831.97,100,MS-DRG,19451.01,Case Rate,100% of CMS IPPS Rate,790,46955.95,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29065.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22422.22,135,MS-DRG,17937.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16609.05,100,MS-DRG,13287.24,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16609.05,100,MS-DRG,13287.24,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16609.05,100,MS-DRG,12501.2,Case Rate,100% of CMS IPPS Rate,790,29065.84,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38434.04,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29649.12,135,MS-DRG,23719.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21962.31,100,MS-DRG,17569.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21962.31,100,MS-DRG,17569.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21962.31,100,MS-DRG,19909.06,Case Rate,100% of CMS IPPS Rate,790,38434.04,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25551.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19711.17,135,MS-DRG,15768.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14600.87,100,MS-DRG,11680.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14600.87,100,MS-DRG,11680.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14600.87,100,MS-DRG,13655.24,Case Rate,100% of CMS IPPS Rate,790,25551.52,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39589.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30540.29,135,MS-DRG,24432.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22622.44,100,MS-DRG,18097.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22622.44,100,MS-DRG,18097.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22622.44,100,MS-DRG,10887.98,Case Rate,100% of CMS IPPS Rate,790,39589.27,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25614.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19759.96,135,MS-DRG,15807.97,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14637.01,100,MS-DRG,11709.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14637.01,100,MS-DRG,11709.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14637.01,100,MS-DRG,35032.76,Case Rate,100% of CMS IPPS Rate,790,25614.77,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43427.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33500.87,135,MS-DRG,26800.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24815.46,100,MS-DRG,19852.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24815.46,100,MS-DRG,19852.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24815.46,100,MS-DRG,21354.39,Case Rate,100% of CMS IPPS Rate,790,43427.06,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26928.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20773.07,135,MS-DRG,16618.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15387.46,100,MS-DRG,12309.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15387.46,100,MS-DRG,12309.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15387.46,100,MS-DRG,15213.97,Case Rate,100% of CMS IPPS Rate,790,26928.06,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50569.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39011.13,135,MS-DRG,31208.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28897.13,100,MS-DRG,23117.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28897.13,100,MS-DRG,23117.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28897.13,100,MS-DRG,71676.31,Case Rate,100% of CMS IPPS Rate,790,50569.98,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33098.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25532.86,135,MS-DRG,20426.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18913.23,100,MS-DRG,15130.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18913.23,100,MS-DRG,15130.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18913.23,100,MS-DRG,40409.39,Case Rate,100% of CMS IPPS Rate,790,33098.15,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24539.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18930.7,135,MS-DRG,15144.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14022.74,100,MS-DRG,11218.19,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14022.74,100,MS-DRG,11218.19,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14022.74,100,MS-DRG,25291.25,Case Rate,100% of CMS IPPS Rate,790,24539.8,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42549.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32823.58,135,MS-DRG,26258.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24313.76,100,MS-DRG,19451.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24313.76,100,MS-DRG,19451.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24313.76,100,MS-DRG,65728.23,Case Rate,100% of CMS IPPS Rate,790,42549.08,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27346.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21095.78,135,MS-DRG,16876.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15626.5,100,MS-DRG,12501.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15626.5,100,MS-DRG,12501.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15626.5,100,MS-DRG,31996.46,Case Rate,100% of CMS IPPS Rate,790,27346.38,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43551.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33596.55,135,MS-DRG,26877.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24886.33,100,MS-DRG,19909.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24886.33,100,MS-DRG,19909.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24886.33,100,MS-DRG,20449.39,Case Rate,100% of CMS IPPS Rate,790,43551.08,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29870.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23043.22,135,MS-DRG,18434.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17069.05,100,MS-DRG,13655.24,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17069.05,100,MS-DRG,13655.24,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17069.05,100,MS-DRG,39702.3,Case Rate,100% of CMS IPPS Rate,790,29870.84,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23817.47,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18373.47,135,MS-DRG,14698.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13609.98,100,MS-DRG,10887.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13609.98,100,MS-DRG,10887.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13609.98,100,MS-DRG,21962.54,Case Rate,100% of CMS IPPS Rate,790,23817.47,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,76634.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59117.78,135,MS-DRG,47294.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43790.95,100,MS-DRG,35032.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43790.95,100,MS-DRG,35032.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43790.95,100,MS-DRG,17516.5,Case Rate,100% of CMS IPPS Rate,790,76634.16,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46712.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36035.54,135,MS-DRG,28828.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26692.99,100,MS-DRG,21354.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26692.99,100,MS-DRG,21354.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26692.99,100,MS-DRG,21903.62,Case Rate,100% of CMS IPPS Rate,790,46712.73,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33280.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,25673.57,135,MS-DRG,20538.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19017.46,100,MS-DRG,15213.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19017.46,100,MS-DRG,15213.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19017.46,100,MS-DRG,19464.35,Case Rate,100% of CMS IPPS Rate,790,33280.56,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,156791.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,120953.78,135,MS-DRG,96763.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,89595.39,100,MS-DRG,71676.31,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,89595.39,100,MS-DRG,71676.31,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,89595.39,100,MS-DRG,24319.54,Case Rate,100% of CMS IPPS Rate,790,156791.93,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,88395.55,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,68190.85,135,MS-DRG,54552.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50511.74,100,MS-DRG,40409.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50511.74,100,MS-DRG,40409.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50511.74,100,MS-DRG,21266.56,Case Rate,100% of CMS IPPS Rate,790,88395.55,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55324.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,42678.98,135,MS-DRG,34143.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31614.06,100,MS-DRG,25291.25,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31614.06,100,MS-DRG,25291.25,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31614.06,100,MS-DRG,25781.55,Case Rate,100% of CMS IPPS Rate,790,55324.61,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,143780.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,110916.39,135,MS-DRG,88733.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,82160.29,100,MS-DRG,65728.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,82160.29,100,MS-DRG,65728.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,82160.29,100,MS-DRG,15995.56,Case Rate,100% of CMS IPPS Rate,790,143780.51,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,69992.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,53994.03,135,MS-DRG,43195.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39995.58,100,MS-DRG,31996.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39995.58,100,MS-DRG,31996.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39995.58,100,MS-DRG,11298.23,Case Rate,100% of CMS IPPS Rate,790,69992.27,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44733.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34508.35,135,MS-DRG,27606.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25561.74,100,MS-DRG,20449.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25561.74,100,MS-DRG,20449.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25561.74,100,MS-DRG,26725.46,Case Rate,100% of CMS IPPS Rate,790,44733.05,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,86848.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,66997.62,135,MS-DRG,53598.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,49627.87,100,MS-DRG,39702.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,49627.87,100,MS-DRG,39702.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,49627.87,100,MS-DRG,13761.97,Case Rate,100% of CMS IPPS Rate,790,86848.77,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48043.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37061.79,135,MS-DRG,29649.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27453.18,100,MS-DRG,21962.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27453.18,100,MS-DRG,21962.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27453.18,100,MS-DRG,20338.22,Case Rate,100% of CMS IPPS Rate,790,48043.07,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38317.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29559.09,135,MS-DRG,23647.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21895.62,100,MS-DRG,17516.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21895.62,100,MS-DRG,17516.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21895.62,100,MS-DRG,15872.14,Case Rate,100% of CMS IPPS Rate,790,38317.34,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47914.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36962.35,135,MS-DRG,29569.88,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27379.52,100,MS-DRG,21903.62,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27379.52,100,MS-DRG,21903.62,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27379.52,100,MS-DRG,10024.12,Case Rate,100% of CMS IPPS Rate,790,47914.16,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42578.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32846.09,135,MS-DRG,26276.87,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24330.44,100,MS-DRG,19464.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24330.44,100,MS-DRG,19464.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24330.44,100,MS-DRG,13945.42,Case Rate,100% of CMS IPPS Rate,790,42578.27,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53199,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41039.23,135,MS-DRG,32831.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30399.43,100,MS-DRG,24319.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30399.43,100,MS-DRG,24319.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30399.43,100,MS-DRG,9587.18,Case Rate,100% of CMS IPPS Rate,790,53199,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46520.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35887.32,135,MS-DRG,28709.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26583.2,100,MS-DRG,21266.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26583.2,100,MS-DRG,21266.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26583.2,100,MS-DRG,19081.89,Case Rate,100% of CMS IPPS Rate,790,46520.6,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56397.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43506.37,135,MS-DRG,34805.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32226.94,100,MS-DRG,25781.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32226.94,100,MS-DRG,25781.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32226.94,100,MS-DRG,12380.02,Case Rate,100% of CMS IPPS Rate,790,56397.15,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34990.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26992.51,135,MS-DRG,21594.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19994.45,100,MS-DRG,15995.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19994.45,100,MS-DRG,15995.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19994.45,100,MS-DRG,19289.79,Case Rate,100% of CMS IPPS Rate,790,34990.29,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24714.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19065.77,135,MS-DRG,15252.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14122.79,100,MS-DRG,11298.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14122.79,100,MS-DRG,11298.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14122.79,100,MS-DRG,12647.95,Case Rate,100% of CMS IPPS Rate,790,24714.88,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58461.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45099.22,135,MS-DRG,36079.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33406.83,100,MS-DRG,26725.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33406.83,100,MS-DRG,26725.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33406.83,100,MS-DRG,20174.78,Case Rate,100% of CMS IPPS Rate,790,58461.95,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30104.31,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23223.32,135,MS-DRG,18578.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17202.46,100,MS-DRG,13761.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17202.46,100,MS-DRG,13761.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17202.46,100,MS-DRG,12477.85,Case Rate,100% of CMS IPPS Rate,790,30104.31,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44489.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34320.75,135,MS-DRG,27456.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25422.78,100,MS-DRG,20338.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25422.78,100,MS-DRG,20338.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25422.78,100,MS-DRG,27585.98,Case Rate,100% of CMS IPPS Rate,790,44489.87,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34720.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26784.24,135,MS-DRG,21427.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19840.18,100,MS-DRG,15872.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19840.18,100,MS-DRG,15872.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19840.18,100,MS-DRG,18899.55,Case Rate,100% of CMS IPPS Rate,790,34720.32,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21927.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16915.7,135,MS-DRG,13532.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12530.15,100,MS-DRG,10024.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12530.15,100,MS-DRG,10024.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12530.15,100,MS-DRG,46545.37,Case Rate,100% of CMS IPPS Rate,790,21927.76,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30505.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23532.89,135,MS-DRG,18826.31,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17431.77,100,MS-DRG,13945.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17431.77,100,MS-DRG,13945.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17431.77,100,MS-DRG,24607.5,Case Rate,100% of CMS IPPS Rate,790,30505.6,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20971.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16178.37,135,MS-DRG,12942.7,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11983.98,100,MS-DRG,9587.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11983.98,100,MS-DRG,9587.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11983.98,100,MS-DRG,15457.46,Case Rate,100% of CMS IPPS Rate,790,20971.97,
CELLULITIS WITH MCC,602,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41741.63,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32200.69,135,MS-DRG,25760.55,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23852.36,100,MS-DRG,19081.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23852.36,100,MS-DRG,19081.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23852.36,100,MS-DRG,31478.37,Case Rate,100% of CMS IPPS Rate,790,41741.63,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27081.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20891.28,135,MS-DRG,16713.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15475.02,100,MS-DRG,12380.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15475.02,100,MS-DRG,12380.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15475.02,100,MS-DRG,20579.46,Case Rate,100% of CMS IPPS Rate,790,27081.29,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42196.42,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32551.52,135,MS-DRG,26041.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24112.24,100,MS-DRG,19289.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24112.24,100,MS-DRG,19289.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24112.24,100,MS-DRG,19413.2,Case Rate,100% of CMS IPPS Rate,790,42196.42,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27667.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21343.42,135,MS-DRG,17074.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15809.94,100,MS-DRG,12647.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15809.94,100,MS-DRG,12647.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15809.94,100,MS-DRG,45076.69,Case Rate,100% of CMS IPPS Rate,790,27667.4,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44132.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34044.95,135,MS-DRG,27235.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25218.48,100,MS-DRG,20174.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25218.48,100,MS-DRG,20174.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25218.48,100,MS-DRG,23238.88,Case Rate,100% of CMS IPPS Rate,790,44132.34,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27295.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21056.37,135,MS-DRG,16845.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15597.31,100,MS-DRG,12477.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15597.31,100,MS-DRG,12477.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15597.31,100,MS-DRG,14934.91,Case Rate,100% of CMS IPPS Rate,790,27295.29,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60344.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46551.35,135,MS-DRG,37241.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34482.48,100,MS-DRG,27585.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34482.48,100,MS-DRG,27585.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34482.48,100,MS-DRG,35021.66,Case Rate,100% of CMS IPPS Rate,790,60344.34,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41342.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31892.99,135,MS-DRG,25514.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23624.44,100,MS-DRG,18899.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23624.44,100,MS-DRG,18899.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23624.44,100,MS-DRG,19130.81,Case Rate,100% of CMS IPPS Rate,790,41342.77,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,101817.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,78545.31,135,MS-DRG,62836.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,58181.71,100,MS-DRG,46545.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,58181.71,100,MS-DRG,46545.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,58181.71,100,MS-DRG,16285.73,Case Rate,100% of CMS IPPS Rate,790,101817.99,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53828.9,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41525.15,135,MS-DRG,33220.12,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30759.37,100,MS-DRG,24607.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30759.37,100,MS-DRG,24607.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30759.37,100,MS-DRG,47176.87,Case Rate,100% of CMS IPPS Rate,790,53828.9,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33813.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26084.46,135,MS-DRG,20867.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19321.82,100,MS-DRG,15457.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19321.82,100,MS-DRG,15457.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19321.82,100,MS-DRG,27701.62,Case Rate,100% of CMS IPPS Rate,790,33813.19,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,68858.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,53119.75,135,MS-DRG,42495.8,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39347.96,100,MS-DRG,31478.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39347.96,100,MS-DRG,31478.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39347.96,100,MS-DRG,18067.94,Case Rate,100% of CMS IPPS Rate,790,68858.93,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45017.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34727.85,135,MS-DRG,27782.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25724.33,100,MS-DRG,20579.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25724.33,100,MS-DRG,20579.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25724.33,100,MS-DRG,18657.19,Case Rate,100% of CMS IPPS Rate,790,45017.58,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42466.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32759.78,135,MS-DRG,26207.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24266.5,100,MS-DRG,19413.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24266.5,100,MS-DRG,19413.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24266.5,100,MS-DRG,12543.45,Case Rate,100% of CMS IPPS Rate,790,42466.38,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,98605.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,76066.91,135,MS-DRG,60853.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,56345.86,100,MS-DRG,45076.69,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,56345.86,100,MS-DRG,45076.69,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,56345.86,100,MS-DRG,9464.9,Case Rate,100% of CMS IPPS Rate,790,98605.26,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50835.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39215.61,135,MS-DRG,31372.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29048.6,100,MS-DRG,23238.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29048.6,100,MS-DRG,23238.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29048.6,100,MS-DRG,17166.27,Case Rate,100% of CMS IPPS Rate,790,50835.05,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32670.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,25202.66,135,MS-DRG,20162.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18668.64,100,MS-DRG,14934.91,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18668.64,100,MS-DRG,14934.91,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18668.64,100,MS-DRG,11231.54,Case Rate,100% of CMS IPPS Rate,790,32670.12,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,76609.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,59099.04,135,MS-DRG,47279.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43777.07,100,MS-DRG,35021.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43777.07,100,MS-DRG,35021.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43777.07,100,MS-DRG,17033.97,Case Rate,100% of CMS IPPS Rate,790,76609.87,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41848.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32283.24,135,MS-DRG,25826.59,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23913.51,100,MS-DRG,19130.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23913.51,100,MS-DRG,19130.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23913.51,100,MS-DRG,20834.07,Case Rate,100% of CMS IPPS Rate,790,41848.64,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35625.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27482.17,135,MS-DRG,21985.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20357.16,100,MS-DRG,16285.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20357.16,100,MS-DRG,16285.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20357.16,100,MS-DRG,14347.88,Case Rate,100% of CMS IPPS Rate,790,35625.03,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,103199.41,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,79610.97,135,MS-DRG,63688.78,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,58971.09,100,MS-DRG,47176.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,58971.09,100,MS-DRG,47176.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,58971.09,100,MS-DRG,11003.62,Case Rate,100% of CMS IPPS Rate,790,103199.41,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,60597.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46746.48,135,MS-DRG,37397.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34627.02,100,MS-DRG,27701.62,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34627.02,100,MS-DRG,27701.62,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34627.02,100,MS-DRG,52546.82,Case Rate,100% of CMS IPPS Rate,790,60597.29,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39523.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30489.64,135,MS-DRG,24391.71,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22584.92,100,MS-DRG,18067.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22584.92,100,MS-DRG,18067.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22584.92,100,MS-DRG,40994.2,Case Rate,100% of CMS IPPS Rate,790,39523.61,
DIABETES WITH MCC,637,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40812.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31484.01,135,MS-DRG,25187.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23321.49,100,MS-DRG,18657.19,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23321.49,100,MS-DRG,18657.19,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23321.49,100,MS-DRG,35946.66,Case Rate,100% of CMS IPPS Rate,790,40812.61,
DIABETES WITH CC,638,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27438.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21167.07,135,MS-DRG,16933.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15679.31,100,MS-DRG,12543.45,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15679.31,100,MS-DRG,12543.45,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15679.31,100,MS-DRG,62731.94,Case Rate,100% of CMS IPPS Rate,790,27438.79,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20704.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15972.01,135,MS-DRG,12777.61,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11831.12,100,MS-DRG,9464.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11831.12,100,MS-DRG,9464.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11831.12,100,MS-DRG,32979.29,Case Rate,100% of CMS IPPS Rate,790,20704.46,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37551.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28968.08,135,MS-DRG,23174.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21457.84,100,MS-DRG,17166.27,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21457.84,100,MS-DRG,17166.27,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21457.84,100,MS-DRG,25978.33,Case Rate,100% of CMS IPPS Rate,790,37551.22,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24569,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18953.23,135,MS-DRG,15162.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14039.43,100,MS-DRG,11231.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14039.43,100,MS-DRG,11231.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14039.43,100,MS-DRG,37427.57,Case Rate,100% of CMS IPPS Rate,790,24569,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37261.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28744.82,135,MS-DRG,22995.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21292.46,100,MS-DRG,17033.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21292.46,100,MS-DRG,17033.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21292.46,100,MS-DRG,23047.66,Case Rate,100% of CMS IPPS Rate,790,37261.81,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45574.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35157.5,135,MS-DRG,28126,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26042.59,100,MS-DRG,20834.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26042.59,100,MS-DRG,20834.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26042.59,100,MS-DRG,19002.96,Case Rate,100% of CMS IPPS Rate,790,45574.53,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31385.99,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24212.05,135,MS-DRG,19369.64,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17934.85,100,MS-DRG,14347.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17934.85,100,MS-DRG,14347.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17934.85,100,MS-DRG,31327.16,Case Rate,100% of CMS IPPS Rate,790,31385.99,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24070.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18568.62,135,MS-DRG,14854.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13754.53,100,MS-DRG,11003.62,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13754.53,100,MS-DRG,11003.62,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13754.53,100,MS-DRG,17507.59,Case Rate,100% of CMS IPPS Rate,790,24070.43,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,114946.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,88672.75,135,MS-DRG,70938.2,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,65683.52,100,MS-DRG,52546.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,65683.52,100,MS-DRG,52546.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,65683.52,100,MS-DRG,14200.02,Case Rate,100% of CMS IPPS Rate,790,114946.16,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,89674.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,69177.71,135,MS-DRG,55342.17,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,51242.75,100,MS-DRG,40994.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,51242.75,100,MS-DRG,40994.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,51242.75,100,MS-DRG,35861.06,Case Rate,100% of CMS IPPS Rate,790,89674.81,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,78633.31,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,60659.98,135,MS-DRG,48527.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44933.32,100,MS-DRG,35946.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44933.32,100,MS-DRG,35946.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44933.32,100,MS-DRG,18765.03,Case Rate,100% of CMS IPPS Rate,790,78633.31,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,137226.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,105860.14,135,MS-DRG,84688.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,78414.92,100,MS-DRG,62731.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,78414.92,100,MS-DRG,62731.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,78414.92,100,MS-DRG,14346.77,Case Rate,100% of CMS IPPS Rate,790,137226.11,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,72142.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,55652.55,135,MS-DRG,44522.04,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,41224.11,100,MS-DRG,32979.29,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,41224.11,100,MS-DRG,32979.29,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41224.11,100,MS-DRG,36888.34,Case Rate,100% of CMS IPPS Rate,790,72142.19,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56827.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,43838.43,135,MS-DRG,35070.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32472.91,100,MS-DRG,25978.33,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32472.91,100,MS-DRG,25978.33,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32472.91,100,MS-DRG,21637.9,Case Rate,100% of CMS IPPS Rate,790,56827.59,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,81872.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,63159.02,135,MS-DRG,50527.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,46784.46,100,MS-DRG,37427.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,46784.46,100,MS-DRG,37427.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,46784.46,100,MS-DRG,14213.35,Case Rate,100% of CMS IPPS Rate,790,81872.81,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50416.75,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38892.92,135,MS-DRG,31114.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28809.57,100,MS-DRG,23047.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28809.57,100,MS-DRG,23047.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28809.57,100,MS-DRG,33874.27,Case Rate,100% of CMS IPPS Rate,790,50416.75,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41568.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,32067.5,135,MS-DRG,25654,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23753.7,100,MS-DRG,19002.96,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23753.7,100,MS-DRG,19002.96,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23753.7,100,MS-DRG,19605.54,Case Rate,100% of CMS IPPS Rate,790,41568.98,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,68528.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,52864.58,135,MS-DRG,42291.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,39158.95,100,MS-DRG,31327.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,39158.95,100,MS-DRG,31327.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39158.95,100,MS-DRG,13246.1,Case Rate,100% of CMS IPPS Rate,790,68528.16,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38297.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29544.06,135,MS-DRG,23635.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21884.49,100,MS-DRG,17507.59,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21884.49,100,MS-DRG,17507.59,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21884.49,100,MS-DRG,21576.75,Case Rate,100% of CMS IPPS Rate,790,38297.86,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31062.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23962.53,135,MS-DRG,19170.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17750.02,100,MS-DRG,14200.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17750.02,100,MS-DRG,14200.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17750.02,100,MS-DRG,12967.03,Case Rate,100% of CMS IPPS Rate,790,31062.54,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,78446.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,60515.53,135,MS-DRG,48412.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,44826.32,100,MS-DRG,35861.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,44826.32,100,MS-DRG,35861.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44826.32,100,MS-DRG,43658.06,Case Rate,100% of CMS IPPS Rate,790,78446.06,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41048.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31665.99,135,MS-DRG,25332.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23456.29,100,MS-DRG,18765.03,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23456.29,100,MS-DRG,18765.03,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23456.29,100,MS-DRG,29029.09,Case Rate,100% of CMS IPPS Rate,790,41048.51,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31383.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,24210.17,135,MS-DRG,19368.14,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17933.46,100,MS-DRG,14346.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17933.46,100,MS-DRG,14346.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17933.46,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,790,31383.56,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,80693.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,62249.07,135,MS-DRG,49799.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,46110.42,100,MS-DRG,36888.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,46110.42,100,MS-DRG,36888.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,46110.42,100,MS-DRG,19229.76,Case Rate,100% of CMS IPPS Rate,790,80693.24,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47332.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36513.96,135,MS-DRG,29211.17,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27047.38,100,MS-DRG,21637.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27047.38,100,MS-DRG,21637.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27047.38,100,MS-DRG,12559.01,Case Rate,100% of CMS IPPS Rate,790,47332.92,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31091.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23985.03,135,MS-DRG,19188.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17766.69,100,MS-DRG,14213.35,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17766.69,100,MS-DRG,14213.35,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17766.69,100,MS-DRG,9309.24,Case Rate,100% of CMS IPPS Rate,790,31091.71,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,74099.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,57162.83,135,MS-DRG,45730.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42342.84,100,MS-DRG,33874.27,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42342.84,100,MS-DRG,33874.27,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42342.84,100,MS-DRG,22994.29,Case Rate,100% of CMS IPPS Rate,790,74099.97,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42887.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33084.36,135,MS-DRG,26467.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24506.93,100,MS-DRG,19605.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24506.93,100,MS-DRG,19605.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24506.93,100,MS-DRG,14165.54,Case Rate,100% of CMS IPPS Rate,790,42887.13,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28975.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,22352.79,135,MS-DRG,17882.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16557.62,100,MS-DRG,13246.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16557.62,100,MS-DRG,13246.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16557.62,100,MS-DRG,11225.97,Case Rate,100% of CMS IPPS Rate,790,28975.84,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,47199.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36410.77,135,MS-DRG,29128.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26970.94,100,MS-DRG,21576.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26970.94,100,MS-DRG,21576.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26970.94,100,MS-DRG,15600.87,Case Rate,100% of CMS IPPS Rate,790,47199.15,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28365.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,21881.87,135,MS-DRG,17505.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16208.79,100,MS-DRG,12967.03,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16208.79,100,MS-DRG,12967.03,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16208.79,100,MS-DRG,11515.04,Case Rate,100% of CMS IPPS Rate,790,28365.38,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,95502,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,73672.97,135,MS-DRG,58938.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,54572.57,100,MS-DRG,43658.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,54572.57,100,MS-DRG,43658.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,54572.57,100,MS-DRG,18290.3,Case Rate,100% of CMS IPPS Rate,790,95502,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,63501.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,48986.59,135,MS-DRG,39189.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,36286.36,100,MS-DRG,29029.09,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,36286.36,100,MS-DRG,29029.09,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,36286.36,100,MS-DRG,11245.98,Case Rate,100% of CMS IPPS Rate,790,63501.13,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44149.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34058.08,135,MS-DRG,27246.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25228.21,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25228.21,100,MS-DRG,20182.57,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25228.21,100,MS-DRG,15841.02,Case Rate,100% of CMS IPPS Rate,790,44149.37,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42065.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32450.22,135,MS-DRG,25960.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24037.2,100,MS-DRG,19229.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24037.2,100,MS-DRG,19229.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24037.2,100,MS-DRG,10238.7,Case Rate,100% of CMS IPPS Rate,790,42065.1,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27472.83,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21193.33,135,MS-DRG,16954.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15698.76,100,MS-DRG,12559.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15698.76,100,MS-DRG,12559.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15698.76,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,790,27472.83,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20363.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15709.34,135,MS-DRG,12567.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11636.55,100,MS-DRG,9309.24,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11636.55,100,MS-DRG,9309.24,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11636.55,100,MS-DRG,20937.47,Case Rate,100% of CMS IPPS Rate,790,20363.96,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50300.01,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38802.86,135,MS-DRG,31042.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28742.86,100,MS-DRG,22994.29,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28742.86,100,MS-DRG,22994.29,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28742.86,100,MS-DRG,13893.16,Case Rate,100% of CMS IPPS Rate,790,50300.01,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30987.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23904.36,135,MS-DRG,19123.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17706.93,100,MS-DRG,14165.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17706.93,100,MS-DRG,14165.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17706.93,100,MS-DRG,10418.81,Case Rate,100% of CMS IPPS Rate,790,30987.13,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24556.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18943.82,135,MS-DRG,15155.06,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14032.46,100,MS-DRG,11225.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14032.46,100,MS-DRG,11225.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14032.46,100,MS-DRG,24356.23,Case Rate,100% of CMS IPPS Rate,790,24556.81,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34126.91,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26326.47,135,MS-DRG,21061.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19501.09,100,MS-DRG,15600.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19501.09,100,MS-DRG,15600.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19501.09,100,MS-DRG,18759.47,Case Rate,100% of CMS IPPS Rate,790,34126.91,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25189.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19431.63,135,MS-DRG,15545.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14393.8,100,MS-DRG,11515.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14393.8,100,MS-DRG,11515.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14393.8,100,MS-DRG,26678.77,Case Rate,100% of CMS IPPS Rate,790,25189.15,
URINARY STONES WITH MCC,693,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40010.04,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30864.89,135,MS-DRG,24691.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22862.88,100,MS-DRG,18290.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22862.88,100,MS-DRG,18290.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22862.88,100,MS-DRG,16967.26,Case Rate,100% of CMS IPPS Rate,790,40010.04,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24600.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18977.6,135,MS-DRG,15182.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14057.48,100,MS-DRG,11245.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14057.48,100,MS-DRG,11245.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14057.48,100,MS-DRG,26146.22,Case Rate,100% of CMS IPPS Rate,790,24600.59,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34652.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26731.73,135,MS-DRG,21385.38,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19801.28,100,MS-DRG,15841.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19801.28,100,MS-DRG,15841.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19801.28,100,MS-DRG,15756.52,Case Rate,100% of CMS IPPS Rate,790,34652.24,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22397.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17277.81,135,MS-DRG,13822.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12798.38,100,MS-DRG,10238.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12798.38,100,MS-DRG,10238.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12798.38,100,MS-DRG,18672.75,Case Rate,100% of CMS IPPS Rate,790,22397.17,
URETHRAL STRICTURE,697,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32636.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25176.39,135,MS-DRG,20141.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18649.18,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18649.18,100,MS-DRG,14919.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18649.18,100,MS-DRG,13200.51,Case Rate,100% of CMS IPPS Rate,790,32636.07,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45800.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35331.98,135,MS-DRG,28265.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26171.84,100,MS-DRG,20937.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26171.84,100,MS-DRG,20937.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26171.84,100,MS-DRG,27086.79,Case Rate,100% of CMS IPPS Rate,790,45800.72,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30391.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23444.71,135,MS-DRG,18755.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17366.45,100,MS-DRG,13893.16,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17366.45,100,MS-DRG,13893.16,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17366.45,100,MS-DRG,18355.89,Case Rate,100% of CMS IPPS Rate,790,30391.29,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22791.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17581.74,135,MS-DRG,14065.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13023.51,100,MS-DRG,10418.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13023.51,100,MS-DRG,10418.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13023.51,100,MS-DRG,22708.56,Case Rate,100% of CMS IPPS Rate,790,22791.14,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53279.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41101.14,135,MS-DRG,32880.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30445.29,100,MS-DRG,24356.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30445.29,100,MS-DRG,24356.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30445.29,100,MS-DRG,15616.43,Case Rate,100% of CMS IPPS Rate,790,53279.26,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41036.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31656.61,135,MS-DRG,25325.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23449.34,100,MS-DRG,18759.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23449.34,100,MS-DRG,18759.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23449.34,100,MS-DRG,23387.86,Case Rate,100% of CMS IPPS Rate,790,41036.35,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58359.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,45020.42,135,MS-DRG,36016.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33348.46,100,MS-DRG,26678.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33348.46,100,MS-DRG,26678.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33348.46,100,MS-DRG,14932.68,Case Rate,100% of CMS IPPS Rate,790,58359.81,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37115.87,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28632.24,135,MS-DRG,22905.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21209.07,100,MS-DRG,16967.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21209.07,100,MS-DRG,16967.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21209.07,100,MS-DRG,11543.94,Case Rate,100% of CMS IPPS Rate,790,37115.87,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57194.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44121.74,135,MS-DRG,35297.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32682.77,100,MS-DRG,26146.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32682.77,100,MS-DRG,26146.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32682.77,100,MS-DRG,16340.22,Case Rate,100% of CMS IPPS Rate,790,57194.85,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34467.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26589.13,135,MS-DRG,21271.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19695.65,100,MS-DRG,15756.52,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19695.65,100,MS-DRG,15756.52,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19695.65,100,MS-DRG,10670.08,Case Rate,100% of CMS IPPS Rate,790,34467.39,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40846.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31510.27,135,MS-DRG,25208.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23340.94,100,MS-DRG,18672.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23340.94,100,MS-DRG,18672.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23340.94,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,790,40846.65,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28876.12,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,22275.86,135,MS-DRG,17820.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16500.64,100,MS-DRG,13200.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16500.64,100,MS-DRG,13200.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16500.64,100,MS-DRG,11439.45,Case Rate,100% of CMS IPPS Rate,790,28876.12,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59252.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,45708.96,135,MS-DRG,36567.17,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33858.49,100,MS-DRG,27086.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33858.49,100,MS-DRG,27086.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33858.49,100,MS-DRG,13705.26,Case Rate,100% of CMS IPPS Rate,790,59252.36,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40153.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30975.56,135,MS-DRG,24780.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22944.86,100,MS-DRG,18355.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22944.86,100,MS-DRG,18355.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22944.86,100,MS-DRG,9454.88,Case Rate,100% of CMS IPPS Rate,790,40153.51,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49674.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,38320.7,135,MS-DRG,30656.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28385.7,100,MS-DRG,22708.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28385.7,100,MS-DRG,22708.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28385.7,100,MS-DRG,26709.89,Case Rate,100% of CMS IPPS Rate,790,49674.98,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34160.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26352.73,135,MS-DRG,21082.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19520.54,100,MS-DRG,15616.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19520.54,100,MS-DRG,15616.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19520.54,100,MS-DRG,16554.78,Case Rate,100% of CMS IPPS Rate,790,34160.95,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51160.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39467.02,135,MS-DRG,31573.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29234.83,100,MS-DRG,23387.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29234.83,100,MS-DRG,23387.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29234.83,100,MS-DRG,45761.56,Case Rate,100% of CMS IPPS Rate,790,51160.95,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,32665.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25198.9,135,MS-DRG,20159.12,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18665.85,100,MS-DRG,14932.68,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18665.85,100,MS-DRG,14932.68,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18665.85,100,MS-DRG,24488.54,Case Rate,100% of CMS IPPS Rate,790,32665.24,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25252.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19480.41,135,MS-DRG,15584.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14429.93,100,MS-DRG,11543.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14429.93,100,MS-DRG,11543.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14429.93,100,MS-DRG,17715.5,Case Rate,100% of CMS IPPS Rate,790,25252.38,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35744.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27574.11,135,MS-DRG,22059.29,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20425.27,100,MS-DRG,16340.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20425.27,100,MS-DRG,16340.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20425.27,100,MS-DRG,42749.71,Case Rate,100% of CMS IPPS Rate,790,35744.22,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23340.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18005.76,135,MS-DRG,14404.61,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13337.6,100,MS-DRG,10670.08,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13337.6,100,MS-DRG,10670.08,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13337.6,100,MS-DRG,22411.71,Case Rate,100% of CMS IPPS Rate,790,23340.8,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44988.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34705.37,135,MS-DRG,27764.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25707.68,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25707.68,100,MS-DRG,20566.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25707.68,100,MS-DRG,16989.5,Case Rate,100% of CMS IPPS Rate,790,44988.44,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25023.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19304.07,135,MS-DRG,15443.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14299.31,100,MS-DRG,11439.45,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14299.31,100,MS-DRG,11439.45,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14299.31,100,MS-DRG,22355,Case Rate,100% of CMS IPPS Rate,790,25023.79,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29980.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23127.63,135,MS-DRG,18502.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17131.58,100,MS-DRG,13705.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17131.58,100,MS-DRG,13705.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17131.58,100,MS-DRG,15463.01,Case Rate,100% of CMS IPPS Rate,790,29980.27,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20682.55,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15955.11,135,MS-DRG,12764.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11818.6,100,MS-DRG,9454.88,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11818.6,100,MS-DRG,9454.88,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11818.6,100,MS-DRG,23472.36,Case Rate,100% of CMS IPPS Rate,790,20682.55,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58427.88,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,45072.94,135,MS-DRG,36058.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33387.36,100,MS-DRG,26709.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33387.36,100,MS-DRG,26709.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33387.36,100,MS-DRG,14061.04,Case Rate,100% of CMS IPPS Rate,790,58427.88,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36213.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27936.2,135,MS-DRG,22348.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20693.48,100,MS-DRG,16554.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20693.48,100,MS-DRG,16554.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20693.48,100,MS-DRG,21178.72,Case Rate,100% of CMS IPPS Rate,790,36213.59,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,100103.41,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77222.63,135,MS-DRG,61778.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57201.95,100,MS-DRG,45761.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57201.95,100,MS-DRG,45761.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57201.95,100,MS-DRG,12407.81,Case Rate,100% of CMS IPPS Rate,790,100103.41,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53568.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41324.4,135,MS-DRG,33059.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30610.67,100,MS-DRG,24488.54,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30610.67,100,MS-DRG,24488.54,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30610.67,100,MS-DRG,18163.55,Case Rate,100% of CMS IPPS Rate,790,53568.67,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38752.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29894.9,135,MS-DRG,23915.92,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22144.37,100,MS-DRG,17715.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22144.37,100,MS-DRG,17715.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22144.37,100,MS-DRG,30530.01,Case Rate,100% of CMS IPPS Rate,790,38752.65,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,93515,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,72140.14,135,MS-DRG,57712.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,53437.14,100,MS-DRG,42749.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,53437.14,100,MS-DRG,42749.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,53437.14,100,MS-DRG,17664.36,Case Rate,100% of CMS IPPS Rate,790,93515,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49025.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37819.76,135,MS-DRG,30255.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28014.64,100,MS-DRG,22411.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28014.64,100,MS-DRG,22411.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28014.64,100,MS-DRG,23139.94,Case Rate,100% of CMS IPPS Rate,790,49025.62,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37164.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28669.77,135,MS-DRG,22935.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21236.87,100,MS-DRG,16989.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21236.87,100,MS-DRG,16989.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21236.87,100,MS-DRG,14603.6,Case Rate,100% of CMS IPPS Rate,790,37164.52,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48901.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37724.06,135,MS-DRG,30179.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27943.75,100,MS-DRG,22355,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27943.75,100,MS-DRG,22355,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27943.75,100,MS-DRG,13547.39,Case Rate,100% of CMS IPPS Rate,790,48901.56,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33825.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,26093.83,135,MS-DRG,20875.06,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19328.76,100,MS-DRG,15463.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19328.76,100,MS-DRG,15463.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19328.76,100,MS-DRG,19127.47,Case Rate,100% of CMS IPPS Rate,790,33825.33,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51345.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39609.61,135,MS-DRG,31687.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29340.45,100,MS-DRG,23472.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29340.45,100,MS-DRG,23472.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29340.45,100,MS-DRG,13579.64,Case Rate,100% of CMS IPPS Rate,790,51345.79,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30758.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23728.01,135,MS-DRG,18982.41,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17576.3,100,MS-DRG,14061.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17576.3,100,MS-DRG,14061.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17576.3,100,MS-DRG,9728.39,Case Rate,100% of CMS IPPS Rate,790,30758.53,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46328.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35739.09,135,MS-DRG,28591.27,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26473.4,100,MS-DRG,21178.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26473.4,100,MS-DRG,21178.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26473.4,100,MS-DRG,13610.76,Case Rate,100% of CMS IPPS Rate,790,46328.45,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27142.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,20938.18,135,MS-DRG,16750.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15509.76,100,MS-DRG,12407.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15509.76,100,MS-DRG,12407.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15509.76,100,MS-DRG,9277.01,Case Rate,100% of CMS IPPS Rate,790,27142.08,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39732.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30650.99,135,MS-DRG,24520.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22704.44,100,MS-DRG,18163.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22704.44,100,MS-DRG,18163.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22704.44,100,MS-DRG,16086.73,Case Rate,100% of CMS IPPS Rate,790,39732.77,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,66784.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,51519.39,135,MS-DRG,41215.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38162.51,100,MS-DRG,30530.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38162.51,100,MS-DRG,30530.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38162.51,100,MS-DRG,19708.94,Case Rate,100% of CMS IPPS Rate,790,66784.39,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38640.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29808.61,135,MS-DRG,23846.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22080.45,100,MS-DRG,17664.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22080.45,100,MS-DRG,17664.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22080.45,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,790,38640.79,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50618.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39048.64,135,MS-DRG,31238.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28924.92,100,MS-DRG,23139.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28924.92,100,MS-DRG,23139.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28924.92,100,MS-DRG,10512.2,Case Rate,100% of CMS IPPS Rate,790,50618.61,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31945.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24643.58,135,MS-DRG,19714.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18254.5,100,MS-DRG,14603.6,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18254.5,100,MS-DRG,14603.6,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18254.5,100,MS-DRG,13541.84,Case Rate,100% of CMS IPPS Rate,790,31945.38,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29634.92,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22861.22,135,MS-DRG,18288.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16934.24,100,MS-DRG,13547.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16934.24,100,MS-DRG,13547.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16934.24,100,MS-DRG,22242.71,Case Rate,100% of CMS IPPS Rate,790,29634.92,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41841.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32277.61,135,MS-DRG,25822.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23909.34,100,MS-DRG,19127.47,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23909.34,100,MS-DRG,19127.47,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23909.34,100,MS-DRG,13929.85,Case Rate,100% of CMS IPPS Rate,790,41841.35,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29705.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22915.64,135,MS-DRG,18332.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16974.55,100,MS-DRG,13579.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16974.55,100,MS-DRG,13579.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16974.55,100,MS-DRG,12175.45,Case Rate,100% of CMS IPPS Rate,790,29705.46,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21280.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16416.66,135,MS-DRG,13133.33,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12160.49,100,MS-DRG,9728.39,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12160.49,100,MS-DRG,9728.39,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12160.49,100,MS-DRG,21994.78,Case Rate,100% of CMS IPPS Rate,790,21280.86,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29773.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22968.16,135,MS-DRG,18374.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17013.45,100,MS-DRG,13610.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17013.45,100,MS-DRG,13610.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17013.45,100,MS-DRG,14230.02,Case Rate,100% of CMS IPPS Rate,790,29773.54,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,20293.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15654.95,135,MS-DRG,12523.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11596.26,100,MS-DRG,9277.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11596.26,100,MS-DRG,9277.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11596.26,100,MS-DRG,12049.81,Case Rate,100% of CMS IPPS Rate,790,20293.46,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35189.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27146.35,135,MS-DRG,21717.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20108.41,100,MS-DRG,16086.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20108.41,100,MS-DRG,16086.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20108.41,100,MS-DRG,22771.93,Case Rate,100% of CMS IPPS Rate,790,35189.72,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43113.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33258.84,135,MS-DRG,26607.07,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24636.18,100,MS-DRG,19708.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24636.18,100,MS-DRG,19708.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24636.18,100,MS-DRG,69252.6,Case Rate,100% of CMS IPPS Rate,790,43113.32,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,24989.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,19277.78,135,MS-DRG,15422.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14279.84,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14279.84,100,MS-DRG,11423.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14279.84,100,MS-DRG,48101.87,Case Rate,100% of CMS IPPS Rate,790,24989.72,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22995.44,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17739.34,135,MS-DRG,14191.47,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13140.25,100,MS-DRG,10512.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13140.25,100,MS-DRG,10512.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13140.25,100,MS-DRG,30033.04,Case Rate,100% of CMS IPPS Rate,790,22995.44,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29622.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22851.86,135,MS-DRG,18281.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16927.3,100,MS-DRG,13541.84,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16927.3,100,MS-DRG,13541.84,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16927.3,100,MS-DRG,49342.64,Case Rate,100% of CMS IPPS Rate,790,29622.78,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,48655.93,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37534.58,135,MS-DRG,30027.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27803.39,100,MS-DRG,22242.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27803.39,100,MS-DRG,22242.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27803.39,100,MS-DRG,19108.58,Case Rate,100% of CMS IPPS Rate,790,48655.93,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,30471.54,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23506.62,135,MS-DRG,18805.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17412.31,100,MS-DRG,13929.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17412.31,100,MS-DRG,13929.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17412.31,100,MS-DRG,4786.46,Case Rate,100% of CMS IPPS Rate,790,30471.54,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,26633.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,20546.07,135,MS-DRG,16436.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15219.31,100,MS-DRG,12175.45,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15219.31,100,MS-DRG,12175.45,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15219.31,100,MS-DRG,18313.64,Case Rate,100% of CMS IPPS Rate,790,26633.79,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,48113.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37116.2,135,MS-DRG,29692.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27493.48,100,MS-DRG,21994.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27493.48,100,MS-DRG,21994.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27493.48,100,MS-DRG,13616.32,Case Rate,100% of CMS IPPS Rate,790,48113.59,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,31128.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,24013.17,135,MS-DRG,19210.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17787.53,100,MS-DRG,14230.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17787.53,100,MS-DRG,14230.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17787.53,100,MS-DRG,11828.56,Case Rate,100% of CMS IPPS Rate,790,31128.18,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,3702,100,,,Per Diem,Pays based on per day rate,4142.1,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,26358.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,2400,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,20334.05,135,MS-DRG,16267.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15062.26,100,MS-DRG,12049.81,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15062.26,100,MS-DRG,12049.81,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15062.26,100,MS-DRG,57628.82,Case Rate,100% of CMS IPPS Rate,790,26358.96,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49813.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38427.63,135,MS-DRG,30742.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28464.91,100,MS-DRG,22771.93,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28464.91,100,MS-DRG,22771.93,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28464.91,100,MS-DRG,33870.94,Case Rate,100% of CMS IPPS Rate,790,49813.59,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,151490.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,116863.76,135,MS-DRG,93491.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,86565.75,100,MS-DRG,69252.6,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,86565.75,100,MS-DRG,69252.6,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,86565.75,100,MS-DRG,22441.73,Case Rate,100% of CMS IPPS Rate,790,151490.06,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,105222.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,81171.91,135,MS-DRG,64937.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,60127.34,100,MS-DRG,48101.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,60127.34,100,MS-DRG,48101.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,60127.34,100,MS-DRG,40687.33,Case Rate,100% of CMS IPPS Rate,790,105222.85,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,65697.28,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50680.76,135,MS-DRG,40544.61,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37541.3,100,MS-DRG,30033.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37541.3,100,MS-DRG,30033.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37541.3,100,MS-DRG,23203.3,Case Rate,100% of CMS IPPS Rate,790,65697.28,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,107937.03,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,83265.71,135,MS-DRG,66612.57,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,61678.3,100,MS-DRG,49342.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,61678.3,100,MS-DRG,49342.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,61678.3,100,MS-DRG,16001.12,Case Rate,100% of CMS IPPS Rate,790,107937.03,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41800.01,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32245.72,135,MS-DRG,25796.58,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23885.72,100,MS-DRG,19108.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23885.72,100,MS-DRG,19108.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23885.72,100,MS-DRG,13753.08,Case Rate,100% of CMS IPPS Rate,790,41800.01,
NORMAL NEWBORN,795,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,10470.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,8077.16,135,MS-DRG,6461.73,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,5983.08,100,MS-DRG,4786.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,5983.08,100,MS-DRG,4786.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,5983.08,100,MS-DRG,10845.74,Case Rate,100% of CMS IPPS Rate,790,10470.39,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,40061.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,30904.27,135,MS-DRG,24723.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22892.05,100,MS-DRG,18313.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22892.05,100,MS-DRG,18313.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22892.05,100,MS-DRG,9818.44,Case Rate,100% of CMS IPPS Rate,790,40061.09,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,29785.7,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,22977.54,135,MS-DRG,18382.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17020.4,100,MS-DRG,13616.32,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17020.4,100,MS-DRG,13616.32,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17020.4,100,MS-DRG,26893.34,Case Rate,100% of CMS IPPS Rate,790,29785.7,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,25874.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,19960.7,135,MS-DRG,15968.56,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14785.7,100,MS-DRG,11828.56,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14785.7,100,MS-DRG,11828.56,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14785.7,100,MS-DRG,15934.41,Case Rate,100% of CMS IPPS Rate,790,25874.98,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,126063.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,97248.64,135,MS-DRG,77798.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,72036.03,100,MS-DRG,57628.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,72036.03,100,MS-DRG,57628.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,72036.03,100,MS-DRG,13711.94,Case Rate,100% of CMS IPPS Rate,790,126063.05,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,74092.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,57157.2,135,MS-DRG,45725.76,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42338.67,100,MS-DRG,33870.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42338.67,100,MS-DRG,33870.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42338.67,100,MS-DRG,18149.1,Case Rate,100% of CMS IPPS Rate,790,74092.67,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49091.28,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,37870.42,135,MS-DRG,30296.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28052.16,100,MS-DRG,22441.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28052.16,100,MS-DRG,22441.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28052.16,100,MS-DRG,12557.9,Case Rate,100% of CMS IPPS Rate,790,49091.28,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,89003.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,68659.87,135,MS-DRG,54927.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50859.16,100,MS-DRG,40687.33,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50859.16,100,MS-DRG,40687.33,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50859.16,100,MS-DRG,19887.95,Case Rate,100% of CMS IPPS Rate,790,89003.53,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50757.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39155.58,135,MS-DRG,31324.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29004.13,100,MS-DRG,23203.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29004.13,100,MS-DRG,23203.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29004.13,100,MS-DRG,26204.02,Case Rate,100% of CMS IPPS Rate,790,50757.23,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35002.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27001.89,135,MS-DRG,21601.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20001.4,100,MS-DRG,16001.12,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20001.4,100,MS-DRG,16001.12,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20001.4,100,MS-DRG,13597.42,Case Rate,100% of CMS IPPS Rate,790,35002.45,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,30084.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,23208.32,135,MS-DRG,18566.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17191.35,100,MS-DRG,13753.08,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17191.35,100,MS-DRG,13753.08,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17191.35,100,MS-DRG,10439.94,Case Rate,100% of CMS IPPS Rate,790,30084.86,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,23725.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,18302.19,135,MS-DRG,14641.75,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13557.18,100,MS-DRG,10845.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13557.18,100,MS-DRG,10845.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13557.18,100,MS-DRG,33860.94,Case Rate,100% of CMS IPPS Rate,790,23725.07,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,2413.6,100,,,Per Diem,Pays based on per day rate,2704.9,100,,,Per Diem,Pays based on per day rate,1600,100,,,Per Diem,Pays based on per day rate,21477.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,1800,100,,,Per Diem,Pays based on per day rate,,,,,Per Diem,Pays based on per day rate,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,16568.62,135,MS-DRG,13254.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12273.05,100,MS-DRG,9818.44,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12273.05,100,MS-DRG,9818.44,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12273.05,100,MS-DRG,18454.84,Case Rate,100% of CMS IPPS Rate,790,21477.84,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58829.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45382.5,135,MS-DRG,36306,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33616.67,100,MS-DRG,26893.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33616.67,100,MS-DRG,26893.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33616.67,100,MS-DRG,12630.17,Case Rate,100% of CMS IPPS Rate,790,58829.17,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,34856.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26889.31,135,MS-DRG,21511.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19918.01,100,MS-DRG,15934.41,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19918.01,100,MS-DRG,15934.41,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19918.01,100,MS-DRG,69770.69,Case Rate,100% of CMS IPPS Rate,790,34856.52,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29994.86,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23138.89,135,MS-DRG,18511.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17139.92,100,MS-DRG,13711.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17139.92,100,MS-DRG,13711.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17139.92,100,MS-DRG,27360.3,Case Rate,100% of CMS IPPS Rate,790,29994.86,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39701.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30626.6,135,MS-DRG,24501.28,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22686.37,100,MS-DRG,18149.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22686.37,100,MS-DRG,18149.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22686.37,100,MS-DRG,16316.86,Case Rate,100% of CMS IPPS Rate,790,39701.15,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27470.4,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21191.45,135,MS-DRG,16953.16,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15697.37,100,MS-DRG,12557.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15697.37,100,MS-DRG,12557.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15697.37,100,MS-DRG,52595.74,Case Rate,100% of CMS IPPS Rate,790,27470.4,
COAGULATION DISORDERS,813,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43504.9,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33560.92,135,MS-DRG,26848.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24859.94,100,MS-DRG,19887.95,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24859.94,100,MS-DRG,19887.95,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24859.94,100,MS-DRG,27369.18,Case Rate,100% of CMS IPPS Rate,790,43504.9,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57321.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,44219.29,135,MS-DRG,35375.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32755.03,100,MS-DRG,26204.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32755.03,100,MS-DRG,26204.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32755.03,100,MS-DRG,16901.66,Case Rate,100% of CMS IPPS Rate,790,57321.3,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,29744.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22945.65,135,MS-DRG,18356.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16996.78,100,MS-DRG,13597.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16996.78,100,MS-DRG,13597.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16996.78,100,MS-DRG,53994.38,Case Rate,100% of CMS IPPS Rate,790,29744.37,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22837.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17617.39,135,MS-DRG,14093.91,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13049.92,100,MS-DRG,10439.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13049.92,100,MS-DRG,10439.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13049.92,100,MS-DRG,28306.43,Case Rate,100% of CMS IPPS Rate,790,22837.36,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,74070.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,57140.33,135,MS-DRG,45712.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,42326.17,100,MS-DRG,33860.94,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,42326.17,100,MS-DRG,33860.94,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42326.17,100,MS-DRG,20781.82,Case Rate,100% of CMS IPPS Rate,790,74070.8,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40369.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,31142.54,135,MS-DRG,24914.03,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23068.55,100,MS-DRG,18454.84,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23068.55,100,MS-DRG,18454.84,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23068.55,100,MS-DRG,37607.67,Case Rate,100% of CMS IPPS Rate,790,40369.96,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27628.49,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,21313.41,135,MS-DRG,17050.73,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15787.71,100,MS-DRG,12630.17,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15787.71,100,MS-DRG,12630.17,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15787.71,100,MS-DRG,20123.63,Case Rate,100% of CMS IPPS Rate,790,27628.49,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,152623.38,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,117738.04,135,MS-DRG,94190.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,87213.36,100,MS-DRG,69770.69,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,87213.36,100,MS-DRG,69770.69,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,87213.36,100,MS-DRG,14499.09,Case Rate,100% of CMS IPPS Rate,790,152623.38,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59850.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46170.5,135,MS-DRG,36936.4,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34200.37,100,MS-DRG,27360.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34200.37,100,MS-DRG,27360.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34200.37,100,MS-DRG,10745.68,Case Rate,100% of CMS IPPS Rate,790,59850.65,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35693.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27534.71,135,MS-DRG,22027.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20396.08,100,MS-DRG,16316.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20396.08,100,MS-DRG,16316.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20396.08,100,MS-DRG,8234.14,Case Rate,100% of CMS IPPS Rate,790,35693.14,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,115053.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,88755.3,135,MS-DRG,71004.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,65744.67,100,MS-DRG,52595.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,65744.67,100,MS-DRG,52595.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,65744.67,100,MS-DRG,64793.2,Case Rate,100% of CMS IPPS Rate,790,115053.17,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59870.09,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,46185.5,135,MS-DRG,36948.4,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34211.48,100,MS-DRG,27369.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34211.48,100,MS-DRG,27369.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34211.48,100,MS-DRG,27398.1,Case Rate,100% of CMS IPPS Rate,790,59870.09,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36972.39,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28521.56,135,MS-DRG,22817.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21127.08,100,MS-DRG,16901.66,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21127.08,100,MS-DRG,16901.66,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21127.08,100,MS-DRG,18241.38,Case Rate,100% of CMS IPPS Rate,790,36972.39,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,118112.7,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,91115.51,135,MS-DRG,72892.41,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,67492.97,100,MS-DRG,53994.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,67492.97,100,MS-DRG,53994.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,67492.97,100,MS-DRG,56399.18,Case Rate,100% of CMS IPPS Rate,790,118112.7,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,61920.32,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,47767.1,135,MS-DRG,38213.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,35383.04,100,MS-DRG,28306.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,35383.04,100,MS-DRG,28306.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35383.04,100,MS-DRG,24798.71,Case Rate,100% of CMS IPPS Rate,790,61920.32,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45460.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,35069.33,135,MS-DRG,28055.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25977.28,100,MS-DRG,20781.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25977.28,100,MS-DRG,20781.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25977.28,100,MS-DRG,17031.74,Case Rate,100% of CMS IPPS Rate,790,45460.24,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,82266.78,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,63462.95,135,MS-DRG,50770.36,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47009.59,100,MS-DRG,37607.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47009.59,100,MS-DRG,37607.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47009.59,100,MS-DRG,37289.7,Case Rate,100% of CMS IPPS Rate,790,82266.78,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44020.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,33958.63,135,MS-DRG,27166.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25154.54,100,MS-DRG,20123.63,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25154.54,100,MS-DRG,20123.63,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25154.54,100,MS-DRG,20038.03,Case Rate,100% of CMS IPPS Rate,790,44020.45,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31716.76,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,24467.21,135,MS-DRG,19573.77,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18123.86,100,MS-DRG,14499.09,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18123.86,100,MS-DRG,14499.09,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18123.86,100,MS-DRG,14400.14,Case Rate,100% of CMS IPPS Rate,790,31716.76,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,23506.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,18133.34,135,MS-DRG,14506.67,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,13432.1,100,MS-DRG,10745.68,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,13432.1,100,MS-DRG,10745.68,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,13432.1,100,MS-DRG,23229.99,Case Rate,100% of CMS IPPS Rate,790,23506.18,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,18012.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,13895.12,135,MS-DRG,11116.1,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,10292.68,100,MS-DRG,8234.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,10292.68,100,MS-DRG,8234.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,10292.68,100,MS-DRG,15409.64,Case Rate,100% of CMS IPPS Rate,790,18012.19,
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,141735.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,109338.53,135,MS-DRG,87470.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,80991.5,100,MS-DRG,64793.2,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,80991.5,100,MS-DRG,64793.2,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,80991.5,100,MS-DRG,12159.87,Case Rate,100% of CMS IPPS Rate,790,141735.13,
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,59933.34,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,46234.29,135,MS-DRG,36987.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,34247.62,100,MS-DRG,27398.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,34247.62,100,MS-DRG,27398.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34247.62,100,MS-DRG,29716.18,Case Rate,100% of CMS IPPS Rate,790,59933.34,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,39903.01,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30782.32,135,MS-DRG,24625.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22801.72,100,MS-DRG,18241.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22801.72,100,MS-DRG,18241.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22801.72,100,MS-DRG,16025.58,Case Rate,100% of CMS IPPS Rate,790,39903.01,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,123373.22,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,95173.62,135,MS-DRG,76138.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,70498.98,100,MS-DRG,56399.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,70498.98,100,MS-DRG,56399.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,70498.98,100,MS-DRG,11840.78,Case Rate,100% of CMS IPPS Rate,790,123373.22,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,54247.18,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41847.83,135,MS-DRG,33478.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30998.39,100,MS-DRG,24798.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30998.39,100,MS-DRG,24798.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30998.39,100,MS-DRG,32466.75,Case Rate,100% of CMS IPPS Rate,790,54247.18,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37256.94,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28741.07,135,MS-DRG,22992.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21289.68,100,MS-DRG,17031.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21289.68,100,MS-DRG,17031.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21289.68,100,MS-DRG,58125.79,Case Rate,100% of CMS IPPS Rate,790,37256.94,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,81571.21,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,62926.36,135,MS-DRG,50341.09,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,46612.12,100,MS-DRG,37289.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,46612.12,100,MS-DRG,37289.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,46612.12,100,MS-DRG,25204.53,Case Rate,100% of CMS IPPS Rate,790,81571.21,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,43833.2,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33814.18,135,MS-DRG,27051.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25047.54,100,MS-DRG,20038.03,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25047.54,100,MS-DRG,20038.03,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25047.54,100,MS-DRG,21464.46,Case Rate,100% of CMS IPPS Rate,790,43833.2,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31500.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24300.23,135,MS-DRG,19440.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18000.17,100,MS-DRG,14400.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18000.17,100,MS-DRG,14400.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18000.17,100,MS-DRG,51778.58,Case Rate,100% of CMS IPPS Rate,790,31500.3,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50815.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39200.61,135,MS-DRG,31360.49,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29037.49,100,MS-DRG,23229.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29037.49,100,MS-DRG,23229.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29037.49,100,MS-DRG,26288.53,Case Rate,100% of CMS IPPS Rate,790,50815.61,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,33708.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26003.77,135,MS-DRG,20803.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,19262.05,100,MS-DRG,15409.64,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,19262.05,100,MS-DRG,15409.64,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19262.05,100,MS-DRG,16812.73,Case Rate,100% of CMS IPPS Rate,790,33708.59,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26599.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20519.78,135,MS-DRG,16415.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15199.84,100,MS-DRG,12159.87,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15199.84,100,MS-DRG,12159.87,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15199.84,100,MS-DRG,23023.19,Case Rate,100% of CMS IPPS Rate,790,26599.72,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,65004.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50146.06,135,MS-DRG,40116.85,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37145.23,100,MS-DRG,29716.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37145.23,100,MS-DRG,29716.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37145.23,100,MS-DRG,13723.06,Case Rate,100% of CMS IPPS Rate,790,65004.15,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35055.95,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27043.16,135,MS-DRG,21634.53,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20031.97,100,MS-DRG,16025.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20031.97,100,MS-DRG,16025.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20031.97,100,MS-DRG,12358.89,Case Rate,100% of CMS IPPS Rate,790,35055.95,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25901.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19981.32,135,MS-DRG,15985.06,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14800.98,100,MS-DRG,11840.78,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14800.98,100,MS-DRG,11840.78,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14800.98,100,MS-DRG,20776.26,Case Rate,100% of CMS IPPS Rate,790,25901.72,
RADIOTHERAPY,849,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,71021.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,54787.64,135,MS-DRG,43830.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,40583.44,100,MS-DRG,32466.75,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,40583.44,100,MS-DRG,32466.75,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,40583.44,100,MS-DRG,12746.9,Case Rate,100% of CMS IPPS Rate,790,71021.02,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,,,,,Other,Not Seperately Reimbusable,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,,,,25806.01,Other,Not Seperately Reimbusable,790,1991.58,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,127150.17,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,98087.27,135,MS-DRG,78469.82,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,72657.24,100,MS-DRG,58125.79,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,72657.24,100,MS-DRG,58125.79,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,72657.24,100,MS-DRG,14612.49,Case Rate,100% of CMS IPPS Rate,790,127150.17,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55134.91,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,42532.64,135,MS-DRG,34026.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31505.66,100,MS-DRG,25204.53,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31505.66,100,MS-DRG,25204.53,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31505.66,100,MS-DRG,10223.14,Case Rate,100% of CMS IPPS Rate,790,55134.91,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46953.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36221.28,135,MS-DRG,28977.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26830.58,100,MS-DRG,21464.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26830.58,100,MS-DRG,21464.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26830.58,100,MS-DRG,79979.18,Case Rate,100% of CMS IPPS Rate,790,46953.52,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,113265.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,87376.35,135,MS-DRG,69901.08,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,64723.22,100,MS-DRG,51778.58,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,64723.22,100,MS-DRG,51778.58,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,64723.22,100,MS-DRG,24586.37,Case Rate,100% of CMS IPPS Rate,790,113265.64,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,57506.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44361.89,135,MS-DRG,35489.51,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32860.66,100,MS-DRG,26288.53,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32860.66,100,MS-DRG,26288.53,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32860.66,100,MS-DRG,13994.34,Case Rate,100% of CMS IPPS Rate,790,57506.16,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36777.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,28371.48,135,MS-DRG,22697.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21015.91,100,MS-DRG,16812.73,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21015.91,100,MS-DRG,16812.73,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21015.91,100,MS-DRG,44030.49,Case Rate,100% of CMS IPPS Rate,790,36777.84,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50363.23,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38851.64,135,MS-DRG,31081.31,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28778.99,100,MS-DRG,23023.19,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28778.99,100,MS-DRG,23023.19,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28778.99,100,MS-DRG,13157.15,Case Rate,100% of CMS IPPS Rate,790,50363.23,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30019.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23157.66,135,MS-DRG,18526.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17153.82,100,MS-DRG,13723.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17153.82,100,MS-DRG,13723.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17153.82,100,MS-DRG,12622.38,Case Rate,100% of CMS IPPS Rate,790,30019.19,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27035.07,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20855.62,135,MS-DRG,16684.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15448.61,100,MS-DRG,12358.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15448.61,100,MS-DRG,12358.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15448.61,100,MS-DRG,12987.04,Case Rate,100% of CMS IPPS Rate,790,27035.07,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45448.08,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35059.95,135,MS-DRG,28047.96,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25970.33,100,MS-DRG,20776.26,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25970.33,100,MS-DRG,20776.26,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25970.33,100,MS-DRG,23394.53,Case Rate,100% of CMS IPPS Rate,790,45448.08,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27883.84,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21510.39,135,MS-DRG,17208.31,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15933.62,100,MS-DRG,12746.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15933.62,100,MS-DRG,12746.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15933.62,100,MS-DRG,22077.06,Case Rate,100% of CMS IPPS Rate,790,27883.84,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56450.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43547.64,135,MS-DRG,34838.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32257.51,100,MS-DRG,25806.01,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32257.51,100,MS-DRG,25806.01,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32257.51,100,MS-DRG,17735.51,Case Rate,100% of CMS IPPS Rate,790,56450.64,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31964.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24658.57,135,MS-DRG,19726.86,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18265.61,100,MS-DRG,14612.49,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18265.61,100,MS-DRG,14612.49,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18265.61,100,MS-DRG,21240.99,Case Rate,100% of CMS IPPS Rate,790,31964.82,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22363.11,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17251.54,135,MS-DRG,13801.23,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12778.92,100,MS-DRG,10223.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12778.92,100,MS-DRG,10223.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12778.92,100,MS-DRG,16948.37,Case Rate,100% of CMS IPPS Rate,790,22363.11,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,174954.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,134964.86,135,MS-DRG,107971.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,99973.97,100,MS-DRG,79979.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,99973.97,100,MS-DRG,79979.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,99973.97,100,MS-DRG,8931.22,Case Rate,100% of CMS IPPS Rate,790,174954.45,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,53782.68,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41489.5,135,MS-DRG,33191.6,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,30732.96,100,MS-DRG,24586.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,30732.96,100,MS-DRG,24586.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30732.96,100,MS-DRG,20430.5,Case Rate,100% of CMS IPPS Rate,790,53782.68,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30612.61,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23615.44,135,MS-DRG,18892.35,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17492.92,100,MS-DRG,13994.34,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17492.92,100,MS-DRG,13994.34,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17492.92,100,MS-DRG,22312.76,Case Rate,100% of CMS IPPS Rate,790,30612.61,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,96316.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,74301.45,135,MS-DRG,59441.16,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,55038.11,100,MS-DRG,44030.49,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,55038.11,100,MS-DRG,44030.49,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,55038.11,100,MS-DRG,12056.49,Case Rate,100% of CMS IPPS Rate,790,96316.69,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28781.27,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22202.69,135,MS-DRG,17762.15,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16446.44,100,MS-DRG,13157.15,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16446.44,100,MS-DRG,13157.15,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16446.44,100,MS-DRG,50660.1,Case Rate,100% of CMS IPPS Rate,790,28781.27,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27611.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21300.26,135,MS-DRG,17040.21,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15777.97,100,MS-DRG,12622.38,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15777.97,100,MS-DRG,12622.38,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15777.97,100,MS-DRG,23497.93,Case Rate,100% of CMS IPPS Rate,790,27611.45,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28409.15,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21915.63,135,MS-DRG,17532.5,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16233.8,100,MS-DRG,12987.04,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16233.8,100,MS-DRG,12987.04,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16233.8,100,MS-DRG,16346.89,Case Rate,100% of CMS IPPS Rate,790,28409.15,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51175.53,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,39478.27,135,MS-DRG,31582.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29243.16,100,MS-DRG,23394.53,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29243.16,100,MS-DRG,23394.53,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29243.16,100,MS-DRG,38746.14,Case Rate,100% of CMS IPPS Rate,790,51175.53,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48293.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37255.03,135,MS-DRG,29804.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27596.32,100,MS-DRG,22077.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27596.32,100,MS-DRG,22077.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27596.32,100,MS-DRG,20151.43,Case Rate,100% of CMS IPPS Rate,790,48293.56,
PSYCHOSES,885,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38796.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29928.68,135,MS-DRG,23942.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22169.39,100,MS-DRG,17735.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22169.39,100,MS-DRG,17735.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22169.39,100,MS-DRG,23463.46,Case Rate,100% of CMS IPPS Rate,790,38796.43,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46464.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,35844.17,135,MS-DRG,28675.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26551.24,100,MS-DRG,21240.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26551.24,100,MS-DRG,21240.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26551.24,100,MS-DRG,43897.07,Case Rate,100% of CMS IPPS Rate,790,46464.67,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,37074.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28600.37,135,MS-DRG,22880.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,21185.46,100,MS-DRG,16948.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,21185.46,100,MS-DRG,16948.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21185.46,100,MS-DRG,24825.42,Case Rate,100% of CMS IPPS Rate,790,37074.56,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,19537.05,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15071.44,135,MS-DRG,12057.15,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11164.03,100,MS-DRG,8931.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11164.03,100,MS-DRG,8931.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11164.03,100,MS-DRG,17623.22,Case Rate,100% of CMS IPPS Rate,790,19537.05,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44691.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34476.48,135,MS-DRG,27581.18,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25538.13,100,MS-DRG,20430.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25538.13,100,MS-DRG,20430.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25538.13,100,MS-DRG,19159.72,Case Rate,100% of CMS IPPS Rate,790,44691.73,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48809.16,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37652.78,135,MS-DRG,30122.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27890.95,100,MS-DRG,22312.76,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27890.95,100,MS-DRG,22312.76,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27890.95,100,MS-DRG,12635.72,Case Rate,100% of CMS IPPS Rate,790,48809.16,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26373.57,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20345.32,135,MS-DRG,16276.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15070.61,100,MS-DRG,12056.49,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15070.61,100,MS-DRG,12056.49,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15070.61,100,MS-DRG,22267.17,Case Rate,100% of CMS IPPS Rate,790,26373.57,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,110818.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,85488.91,135,MS-DRG,68391.13,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,63325.12,100,MS-DRG,50660.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,63325.12,100,MS-DRG,50660.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,63325.12,100,MS-DRG,9868.48,Case Rate,100% of CMS IPPS Rate,790,110818.96,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51401.72,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39652.75,135,MS-DRG,31722.2,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29372.41,100,MS-DRG,23497.93,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29372.41,100,MS-DRG,23497.93,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29372.41,100,MS-DRG,20287.07,Case Rate,100% of CMS IPPS Rate,790,51401.72,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,35758.82,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,27585.37,135,MS-DRG,22068.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20433.61,100,MS-DRG,16346.89,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20433.61,100,MS-DRG,16346.89,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20433.61,100,MS-DRG,12115.41,Case Rate,100% of CMS IPPS Rate,790,35758.82,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,84757.19,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,65384.12,135,MS-DRG,52307.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,48432.68,100,MS-DRG,38746.14,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,48432.68,100,MS-DRG,38746.14,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,48432.68,100,MS-DRG,22830.85,Case Rate,100% of CMS IPPS Rate,790,84757.19,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44081.26,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34005.54,135,MS-DRG,27204.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25189.29,100,MS-DRG,20151.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25189.29,100,MS-DRG,20151.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25189.29,100,MS-DRG,14037.7,Case Rate,100% of CMS IPPS Rate,790,44081.26,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,51326.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39594.6,135,MS-DRG,31675.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,29329.33,100,MS-DRG,23463.46,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,29329.33,100,MS-DRG,23463.46,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29329.33,100,MS-DRG,10302.08,Case Rate,100% of CMS IPPS Rate,790,51326.33,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,96024.85,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,74076.31,135,MS-DRG,59261.05,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,54871.34,100,MS-DRG,43897.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,54871.34,100,MS-DRG,43897.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,54871.34,100,MS-DRG,21943.65,Case Rate,100% of CMS IPPS Rate,790,96024.85,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,54305.6,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,41892.89,135,MS-DRG,33514.31,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31031.77,100,MS-DRG,24825.42,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31031.77,100,MS-DRG,24825.42,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31031.77,100,MS-DRG,13788.65,Case Rate,100% of CMS IPPS Rate,790,54305.6,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38550.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,29739.18,135,MS-DRG,23791.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22029.02,100,MS-DRG,17623.22,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22029.02,100,MS-DRG,17623.22,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22029.02,100,MS-DRG,295597.82,Case Rate,100% of CMS IPPS Rate,790,38550.79,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,41911.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32332.03,135,MS-DRG,25865.62,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,23949.65,100,MS-DRG,19159.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,23949.65,100,MS-DRG,19159.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23949.65,100,MS-DRG,79476.63,Case Rate,100% of CMS IPPS Rate,790,41911.89,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,27640.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,21322.78,135,MS-DRG,17058.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15794.65,100,MS-DRG,12635.72,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15794.65,100,MS-DRG,12635.72,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15794.65,100,MS-DRG,38293.65,Case Rate,100% of CMS IPPS Rate,790,27640.64,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48709.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37575.85,135,MS-DRG,30060.68,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27833.96,100,MS-DRG,22267.17,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27833.96,100,MS-DRG,22267.17,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27833.96,100,MS-DRG,36253.51,Case Rate,100% of CMS IPPS Rate,790,48709.43,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21587.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16653.06,135,MS-DRG,13322.45,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12335.6,100,MS-DRG,9868.48,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12335.6,100,MS-DRG,9868.48,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12335.6,100,MS-DRG,25808.23,Case Rate,100% of CMS IPPS Rate,790,21587.3,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,44377.97,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,34234.43,135,MS-DRG,27387.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25358.84,100,MS-DRG,20287.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25358.84,100,MS-DRG,20287.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25358.84,100,MS-DRG,25236.77,Case Rate,100% of CMS IPPS Rate,790,44377.97,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26502.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20444.75,135,MS-DRG,16355.8,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,15144.26,100,MS-DRG,12115.41,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,15144.26,100,MS-DRG,12115.41,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15144.26,100,MS-DRG,38291.43,Case Rate,100% of CMS IPPS Rate,790,26502.46,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,49942.48,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38527.06,135,MS-DRG,30821.65,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28538.56,100,MS-DRG,22830.85,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28538.56,100,MS-DRG,22830.85,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28538.56,100,MS-DRG,26632.07,Case Rate,100% of CMS IPPS Rate,790,49942.48,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30707.46,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23688.61,135,MS-DRG,18950.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17547.12,100,MS-DRG,14037.7,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17547.12,100,MS-DRG,14037.7,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17547.12,100,MS-DRG,23178.84,Case Rate,100% of CMS IPPS Rate,790,30707.46,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,22535.8,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17384.76,135,MS-DRG,13907.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12877.6,100,MS-DRG,10302.08,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12877.6,100,MS-DRG,10302.08,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12877.6,100,MS-DRG,19326.49,Case Rate,100% of CMS IPPS Rate,790,22535.8,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,48001.73,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37029.91,135,MS-DRG,29623.93,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,27429.56,100,MS-DRG,21943.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,27429.56,100,MS-DRG,21943.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27429.56,100,MS-DRG,13803.1,Case Rate,100% of CMS IPPS Rate,790,48001.73,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30162.67,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23268.34,135,MS-DRG,18614.67,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17235.81,100,MS-DRG,13788.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17235.81,100,MS-DRG,13788.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17235.81,100,MS-DRG,16459.18,Case Rate,100% of CMS IPPS Rate,790,30162.67,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,646620.24,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,498821.33,135,MS-DRG,399057.06,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,369497.28,100,MS-DRG,295597.82,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,369497.28,100,MS-DRG,295597.82,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,369497.28,100,MS-DRG,11449.44,Case Rate,100% of CMS IPPS Rate,790,646620.24,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,173855.13,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,134116.82,135,MS-DRG,107293.46,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,99345.79,100,MS-DRG,79476.63,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,99345.79,100,MS-DRG,79476.63,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,99345.79,100,MS-DRG,14471.3,Case Rate,100% of CMS IPPS Rate,790,173855.13,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,83767.36,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,64620.53,135,MS-DRG,51696.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47867.06,100,MS-DRG,38293.65,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47867.06,100,MS-DRG,38293.65,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47867.06,100,MS-DRG,9643.9,Case Rate,100% of CMS IPPS Rate,790,83767.36,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,79304.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,61177.8,135,MS-DRG,48942.24,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,45316.89,100,MS-DRG,36253.51,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,45316.89,100,MS-DRG,36253.51,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,45316.89,100,MS-DRG,9103.55,Case Rate,100% of CMS IPPS Rate,790,79304.56,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,56455.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43551.39,135,MS-DRG,34841.11,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,32260.29,100,MS-DRG,25808.23,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,32260.29,100,MS-DRG,25808.23,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32260.29,100,MS-DRG,70254.32,Case Rate,100% of CMS IPPS Rate,790,56455.51,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,55205.43,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,42587.05,135,MS-DRG,34069.64,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,31545.96,100,MS-DRG,25236.77,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,31545.96,100,MS-DRG,25236.77,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,31545.96,100,MS-DRG,45661.5,Case Rate,100% of CMS IPPS Rate,790,55205.43,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,83762.51,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,64616.79,135,MS-DRG,51693.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,47864.29,100,MS-DRG,38291.43,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,47864.29,100,MS-DRG,38291.43,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,47864.29,100,MS-DRG,82954.32,Case Rate,100% of CMS IPPS Rate,790,83762.51,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,58257.66,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,44941.62,135,MS-DRG,35953.3,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,33290.09,100,MS-DRG,26632.07,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,33290.09,100,MS-DRG,26632.07,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,33290.09,100,MS-DRG,47513.74,Case Rate,100% of CMS IPPS Rate,790,58257.66,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,50703.71,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,39114.29,135,MS-DRG,31291.43,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,28973.55,100,MS-DRG,23178.84,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,28973.55,100,MS-DRG,23178.84,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,28973.55,100,MS-DRG,30699,Case Rate,100% of CMS IPPS Rate,790,50703.71,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42276.69,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32613.45,135,MS-DRG,26090.76,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24158.11,100,MS-DRG,19326.49,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24158.11,100,MS-DRG,19326.49,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24158.11,100,MS-DRG,32943.71,Case Rate,100% of CMS IPPS Rate,790,42276.69,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,30194.29,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,23292.74,135,MS-DRG,18634.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,17253.88,100,MS-DRG,13803.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,17253.88,100,MS-DRG,13803.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,17253.88,100,MS-DRG,19231.99,Case Rate,100% of CMS IPPS Rate,790,30194.29,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,36004.45,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,27774.86,135,MS-DRG,22219.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,20573.97,100,MS-DRG,16459.18,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,20573.97,100,MS-DRG,16459.18,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20573.97,100,MS-DRG,13171.61,Case Rate,100% of CMS IPPS Rate,790,36004.45,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,25045.65,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,19320.93,135,MS-DRG,15456.74,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14311.8,100,MS-DRG,11449.44,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14311.8,100,MS-DRG,11449.44,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14311.8,100,MS-DRG,78952.98,Case Rate,100% of CMS IPPS Rate,790,25045.65,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31655.96,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24420.31,135,MS-DRG,19536.25,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18089.12,100,MS-DRG,14471.3,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18089.12,100,MS-DRG,14471.3,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18089.12,100,MS-DRG,33447.36,Case Rate,100% of CMS IPPS Rate,790,31655.96,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,21096.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16274.07,135,MS-DRG,13019.26,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,12054.87,100,MS-DRG,9643.9,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,12054.87,100,MS-DRG,9643.9,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,12054.87,100,MS-DRG,34969.4,Case Rate,100% of CMS IPPS Rate,790,21096.02,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,19914.02,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,15362.24,135,MS-DRG,12289.79,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,11379.44,100,MS-DRG,9103.55,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,11379.44,100,MS-DRG,9103.55,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,11379.44,100,MS-DRG,17701.05,Case Rate,100% of CMS IPPS Rate,790,19914.02,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,153681.33,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,118554.17,135,MS-DRG,94843.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,87817.9,100,MS-DRG,70254.32,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,87817.9,100,MS-DRG,70254.32,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,87817.9,100,MS-DRG,11941.97,Case Rate,100% of CMS IPPS Rate,790,153681.33,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,99884.52,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,77053.77,135,MS-DRG,61643.02,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,57076.87,100,MS-DRG,45661.5,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,57076.87,100,MS-DRG,45661.5,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,57076.87,100,MS-DRG,18288.06,Case Rate,100% of CMS IPPS Rate,790,99884.52,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,181462.58,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,139985.42,135,MS-DRG,111988.34,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,103692.9,100,MS-DRG,82954.32,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,103692.9,100,MS-DRG,82954.32,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,103692.9,100,MS-DRG,55247.37,Case Rate,100% of CMS IPPS Rate,790,181462.58,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,103936.3,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,80179.43,135,MS-DRG,64143.54,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,59392.17,100,MS-DRG,47513.74,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,59392.17,100,MS-DRG,47513.74,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,59392.17,100,MS-DRG,30183.13,Case Rate,100% of CMS IPPS Rate,790,103936.3,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,67154.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,51804.56,135,MS-DRG,41443.65,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,38373.75,100,MS-DRG,30699,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,38373.75,100,MS-DRG,30699,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,38373.75,100,MS-DRG,20724.02,Case Rate,100% of CMS IPPS Rate,790,67154.06,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,72064.37,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,55592.51,135,MS-DRG,44474.01,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,41179.64,100,MS-DRG,32943.71,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,41179.64,100,MS-DRG,32943.71,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41179.64,100,MS-DRG,40085.86,Case Rate,100% of CMS IPPS Rate,790,72064.37,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,42069.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,32453.99,135,MS-DRG,25963.19,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,24039.99,100,MS-DRG,19231.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,24039.99,100,MS-DRG,19231.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,24039.99,100,MS-DRG,21411.1,Case Rate,100% of CMS IPPS Rate,790,42069.98,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,28812.89,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22227.09,135,MS-DRG,17781.67,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,16464.51,100,MS-DRG,13171.61,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,16464.51,100,MS-DRG,13171.61,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,16464.51,100,MS-DRG,14554.67,Case Rate,100% of CMS IPPS Rate,790,28812.89,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,172709.64,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,133233.15,135,MS-DRG,106586.52,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,98691.22,100,MS-DRG,78952.98,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,98691.22,100,MS-DRG,78952.98,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,98691.22,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,790,172709.64,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,73166.1,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,56442.42,135,MS-DRG,45153.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,41809.2,100,MS-DRG,33447.36,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,41809.2,100,MS-DRG,33447.36,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,41809.2,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,790,73166.1,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,76495.56,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,59010.86,135,MS-DRG,47208.69,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,43711.75,100,MS-DRG,34969.4,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,43711.75,100,MS-DRG,34969.4,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,43711.75,100,MS-DRG,34969.4,Case Rate,100% of CMS IPPS Rate,790,76495.56,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,38721.04,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,29870.52,135,MS-DRG,23896.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22126.31,100,MS-DRG,17701.05,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22126.31,100,MS-DRG,17701.05,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22126.31,100,MS-DRG,17701.05,Case Rate,100% of CMS IPPS Rate,790,38721.04,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,26123.06,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,20152.07,135,MS-DRG,16121.66,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,14927.46,100,MS-DRG,11941.97,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,14927.46,100,MS-DRG,11941.97,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,14927.46,100,MS-DRG,11941.97,Case Rate,100% of CMS IPPS Rate,790,26123.06,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,40005.14,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,868,100,,,Per Diem,Pays based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,30861.11,135,MS-DRG,24688.89,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,22860.08,100,MS-DRG,18288.06,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,22860.08,100,MS-DRG,18288.06,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,22860.08,100,MS-DRG,18288.06,Case Rate,100% of CMS IPPS Rate,790,40005.14,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,120853.62,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,93229.93,135,MS-DRG,74583.94,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,69059.21,100,MS-DRG,55247.37,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,69059.21,100,MS-DRG,55247.37,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,69059.21,100,MS-DRG,55247.37,Case Rate,100% of CMS IPPS Rate,790,120853.62,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,66025.59,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,50934.03,135,MS-DRG,40747.22,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,37728.91,100,MS-DRG,30183.13,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,37728.91,100,MS-DRG,30183.13,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,37728.91,100,MS-DRG,30183.13,Case Rate,100% of CMS IPPS Rate,790,66025.59,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,45333.79,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,34971.78,135,MS-DRG,27977.42,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,25905.02,100,MS-DRG,20724.02,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,25905.02,100,MS-DRG,20724.02,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,25905.02,100,MS-DRG,20724.02,Case Rate,100% of CMS IPPS Rate,790,45333.79,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,87687.81,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,67644.88,135,MS-DRG,54115.9,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,50107.32,100,MS-DRG,40085.86,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,50107.32,100,MS-DRG,40085.86,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,50107.32,100,MS-DRG,40085.86,Case Rate,100% of CMS IPPS Rate,790,87687.81,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,46836.77,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,36131.22,135,MS-DRG,28904.98,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,26763.87,100,MS-DRG,21411.1,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,26763.87,100,MS-DRG,21411.1,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,26763.87,100,MS-DRG,21411.1,Case Rate,100% of CMS IPPS Rate,790,46836.77,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,31838.35,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,24561.01,135,MS-DRG,19648.81,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,18193.34,100,MS-DRG,14554.67,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,18193.34,100,MS-DRG,14554.67,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,18193.34,100,MS-DRG,14554.67,Case Rate,100% of CMS IPPS Rate,790,31838.35,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,5564.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,4292.99,135,MS-DRG,3434.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,790,5564.98,
UNGROUPABLE,999,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,1600,100,,,Per Diem,Pays based on per day rate,5564.98,175,MS-DRG,140,Case Rate,175% of CMS IPPS Rate,,,,,Other,Not Seperately Reimbusable,,,,,Other,Not Seperately Reimbusable,790,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Seperately Reimbusable,1952.53,100,,,Per Diem,Pays based on per day rate,4292.99,135,MS-DRG,3434.39,Case Rate,135% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,1991.58,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays Based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,800,100,,,Per Diem,Pays Based on per day rate,1952.53,100,,,Per Diem,Pays based on per day rate,3179.99,100,MS-DRG,2543.99,Case Rate,100% of CMS IPPS Rate,790,5564.98,